Lessons learned managing geriatric patients offer framework for improved care

A large team of experts led by a Johns Hopkins geriatrician reports that efforts to improve the care of older adults and others 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." Lessons learned from managing such transitions for older patients, 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. In a report published online in the Journal of General Internal Medicine on Feb. 21, 2014, the experts say studies have long shown that fragmented care, incomplete information "handoffs" and poor planning among community-based and home caregivers jeopardize health and safety.

Similarly, the team says, those with traumatic brain injuries, cancer, end-stage kidney failure, complicated diabetes, heart disease, developmental disabilities and cerebral palsy need better coordination of their care across settings.

Using a review of research and clinical experience, the authors built their framework and recommendations for improving care on the foundation of what's been learned about caring for aging Americans.

Among their recommendations for health policymakers and caregivers are the need to engage community-based care "receivers" earlier in the transition process, to adopt a approach with patients and their families that sets realistic care goals, and to focus not only on preventing hospitalization, but also on making out-of-hospital transitions easier.

"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, M.D., M.P.H., 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, Arbaje says, hospital staff should not only make follow-up phone calls to check on discharged patients, but they should also send written care instructions. Family members and caregivers should be a part of patient education during discharge. Small chores, such as alerting a skilled provider well in advance of a patient'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," says Arbaje. Recovery and emergency contingency plans need to be broader than referring a patient back to a primary care physician and instead include other components of an individual patient's health care system and support.

"These findings shed light on what we can do as a health system and community to reduce readmission rates by looking at more than just the patient. The conceptual framework gives structure to understand problems with care transitions and outlines what and who to consider when planning and implementing them. It can be a valuable tool for health care systems and policymakers to guide care coordination efforts as part of ," she says.

More information: The full report is titled "Regardless of Age: Incorporating Principles from Geriatric Medicine to Improve Care Transitions for Patients with Complex Needs."

add to favorites email to friend print save as pdf

Related Stories

Recommended for you

New toilets for India's poor, crime-hit village

14 minutes ago

More than 100 new toilets were unveiled Sunday in a poverty-stricken and scandal-hit village in northern India, where fearful and vulnerable women have long been forced to defecate in the open.

Can YouTube save your life?

Aug 29, 2014

Only a handful of CPR and basic life support (BLS) videos available on YouTube provide instructions which are consistent with recent health guidelines, according to a new study published in Emergency Medicine Australasia, the jo ...

Doctors frequently experience ethical dilemmas

Aug 29, 2014

(HealthDay)—For physicians trying to balance various financial and time pressures, ethical dilemmas are common, according to an article published Aug. 7 in Medical Economics.

AMGA: Physician turnover still high in 2013

Aug 29, 2014

(HealthDay)—For the second year running, physician turnover remains at the highest rate since 2005, according to a report published by the American Medical Group Association (AMGA).

Obese or overweight teens more likely to become smokers

Aug 29, 2014

A study examining whether overweight or obese teens are at higher risk for substance abuse finds both good and bad news: weight status has no correlation with alcohol or marijuana use but is linked to regular ...

User comments