Healthcare transitions of older adults: an overview for the general practitioner

Healthcare transition refers to the care "hand-off" of a patient among providers and treatment settings. Older adults experience more frequent care transitions than younger patients due to the presence of co-morbidities, cognitive impairment, increased dependence and medication use. Hospitalization and subsequent readmission after discharge to a nursing home represents a unique care transition situation. It is estimated that as many as 60% of readmissions from nursing homes can be avoided. Poor communication between hospital and nursing home staff; delayed, inaccurate, or missing discharge summaries; lack of accurate medication reconciliation; pending test results; inappropriate follow-up; and poor education of patient and families all contribute to poor care transition quality, and increase the probability of rehospitalization. Interventions for improved care transitions are suggested. They focus on patient and family-centered care effectiveness, minimizing adverse events, and increasing timely, accurate and complete communication.