Aging patients: nursing implications for direct care nurses

Experience with my mother over the past 3 years led me reflect on how we care for older adults. For those who do not have a nurse in the family to provide care coordination and oversight, how are the gaps in continuity of care and transitions in care addressed? Many specialized positions are emerging for nurses in care coordination. These positions tend to focus on the most complex patients and on selected transitions in care. There are pockets of excellence but nurses who provide direct care in inpatient and outpatient settings are the safety net for older adults like my mother. They need competencies in assessment of older adults and awareness of how illness may present differently in this population. They need to be aware of the entire continuum of care and provide care coordination for patients who are not receiving specialized care coordination services.