Transitional care programs are designed as a crucial bridge in the healthcare system, focusing on the safe and timely movement of patients between different levels of care and various healthcare settings. These programs are especially vital for older adults, particularly those managing multiple chronic conditions and complex medication regimens, along with their dedicated family caregivers. This patient demographic often navigates a fragmented healthcare landscape, interacting with numerous providers and frequently transitioning across diverse care environments. Evidence increasingly highlights that these individuals are particularly susceptible to gaps in care coordination during these transitions, underscoring their significant need for robust transitional care services. Ineffective patient handovers, particularly from hospital to home, have been consistently linked to negative outcomes, including adverse medical events, diminished patient satisfaction, and elevated rates of hospital readmission.
Conceptual graphic representing patient transition between hospital and home, highlighting the role of transitional care in bridging the gap and ensuring continuity of care.
Several factors contribute to breakdowns in care continuity during these critical transition periods. These include inadequate communication among healthcare providers, incomplete or missing transfer of essential patient information, insufficient education and preparation for both patients and their family caregivers, limited access to necessary support services post-discharge, and the absence of a designated point of contact to oversee and ensure seamless care continuity. Furthermore, language barriers, varying levels of health literacy, and cultural differences can significantly compound these challenges, further complicating effective transitional care.
Family caregivers are integral to the support system for older adults, playing a substantial, and arguably the most critical, role in assisting them throughout hospitalization and especially in the crucial period following discharge. Despite their importance, the distinct needs of family caregivers during these transitional phases have historically been largely overlooked. Consequently, family caregivers frequently report dissatisfaction with their level of involvement in discharge planning decisions and express concerns about the adequacy of their preparation for the subsequent stages of caregiving.
While caregiving can be a source of fulfillment, it also places considerable burdens on family caregivers. The inherent stress associated with caregiving is often intensified during episodes of acute illness. Therefore, healthcare professionals, including nurses and social workers, must address the emotional and practical needs of caregivers within transitional care programs. This support is essential to mitigate negative caregiver experiences and enhance their capacity to effectively support their loved ones through healthcare transitions.
Research-Based Innovations in Transitional Care
To better understand the advancements in transitional care models for older adults within the United States, and to examine the crucial roles of family caregivers within these models, extensive research has been conducted. A thorough search of Medline, CINAHL, and Social Work Abstracts databases was performed, utilizing keywords such as “research,” “ages 65 years or older,” “continuity of patient care,” “patient transfer,” “discharge planning,” “postdischarge follow-up,” and “transitional care.” This search covered studies published between 1996 and 2007, aiming to identify evidence-based strategies for improving transitional care.
This research identified three key approaches showing promise in enhancing the quality of care for older adults managing chronic illnesses:
- Expanding Access to Community-Based Transitional Care Services: Making proven community-based services more readily available to older adults to manage acute episodes of chronic conditions.
- Improving Transitions Within Acute Hospital Settings: Streamlining and enhancing the transitions patients experience while moving between different units within a hospital, such as from the emergency department to intensive care units and general medical floors.
- Optimizing Patient Handovers To and From Acute Care Hospitals: Focusing on improving the communication and coordination involved in patient discharges from hospitals to home or other care settings, and admissions back into the hospital when necessary.
It is important to note that while these approaches primarily focus on the patient, they inherently also impact and, to some extent, address the needs of family caregivers. Let’s explore two specific models within each of these categories to illustrate these innovative approaches.
Community-Based Transitional Care Models
Evaluations of various initiatives at the federal, state, and provider levels, all aimed at improving care continuity for high-risk older adults, consistently point to the benefits of increased access to short-term, community-based services. These services are particularly valuable for managing acute exacerbations of chronic illnesses, preventing unnecessary hospitalizations, and supporting recovery at home. The findings from these evaluations have significantly shaped the development and refinement of community-based transitional care models across the United States.
Hospital at Home
For older adults who frequently experience acute episodes related to their chronic conditions, home-based care models like “Hospital at Home” offer a compelling alternative to traditional hospitalization. This model delivers acute-level care in the patient’s residence, providing a range of medical services that would typically be administered in a hospital setting. (For further details, resources are available at www.hospitalathome.org). It’s crucial to further investigate the perspectives of patients, family caregivers, and healthcare providers regarding the advantages and limitations of this innovative care model.
A quasi-experimental study conducted by Leff and colleagues examined the effectiveness of the Hospital at Home model. Community-dwelling older adults with chronic illnesses, who presented to the emergency department and would typically have been admitted to the hospital, were instead enrolled in the study and discharged home. At home, they received comprehensive care, including nursing, physician visits, and other necessary services, all guided by a specific care protocol. The study demonstrated that clinical outcomes achieved in the Hospital at Home setting were comparable to those of traditional acute hospital care. Furthermore, this model resulted in shorter lengths of stay and significant reductions in overall healthcare costs. Patients who participated in the program also reported high levels of satisfaction with the care they received in their homes.
Day Hospital
Another prominent example of community-based transitional care is the “day hospital” model, inspired by successful programs within the British healthcare system. The Collaborative Assessment and Rehabilitation for Elders (CARE) program at the University of Pennsylvania in Philadelphia serves as a prime illustration of this approach. The CARE program operated as a Medicare-certified Comprehensive Outpatient Rehabilitation Facility (CORF). This interdisciplinary program, led by a geriatric nurse practitioner, was specifically designed for community-dwelling older adults identified as being at high risk for hospitalization and other adverse health outcomes. Participants in the CARE program had access to a wide spectrum of health, palliative, and rehabilitation services for several days each week, for a duration of up to nine weeks.
A quasi-experimental study evaluating the CARE program revealed significant improvements in patient function and a reduction in hospital utilization among program participants. Notably, positive outcomes were observed in both cognitively intact and cognitively impaired older adults, indicating the broad applicability and benefit of this model, even for more vulnerable patient populations. Unfortunately, changes in reimbursement policies for CORFs led to the closure of the CARE program. Further research is needed to fully understand the impact of the day hospital model on the needs and outcomes of family caregivers, as well as its potential for wider implementation and sustainability.
Improving Transitions Within Hospital Settings
Frequent transitions within a hospital, such as moving patients from the emergency department (ED) to an intensive care unit (ICU), then to a step-down unit, and finally to a general medical-surgical unit, can be particularly detrimental to the health and well-being of older adults and their family caregivers. These intra-hospital transfers are often associated with increased risks, including serious medication errors and disruptions in care continuity. The following hospital-based transitional care models are specifically designed to mitigate these issues and improve the safety and quality of care during transitions within the hospital setting.
Acute Care for Elders (ACE)
The Acute Care for Elders (ACE) model, pioneered at the University Hospitals of Cleveland in Ohio, is a specialized approach to inpatient care focused on preventing functional decline and enhancing discharge readiness in older adults hospitalized for acute illnesses. Key features of the ACE model include: adapting the physical environment of the hospital unit to better meet the specific needs of older patients (e.g., improved lighting, non-slip flooring, handrails); conducting daily interdisciplinary team conferences to collaboratively plan and coordinate care; implementing nurse-initiated protocols and guidelines for preventive and restorative care interventions; and initiating discharge planning early in the hospital stay, with active involvement of family members in the planning process.
An early randomized controlled trial evaluating the ACE model demonstrated significant benefits for older patients. Patients receiving care in ACE units exhibited higher levels of functional ability at discharge, experienced shorter hospital lengths of stay, and incurred decreased hospital costs compared to patients receiving usual hospital care. The ACE model highlights the importance of a holistic, patient-centered approach to inpatient care for older adults, focusing on maintaining function and facilitating a smoother transition back home.
Professional–Patient Partnership Model
The Professional–Patient Partnership model was implemented in Baltimore with the goal of improving discharge planning and post-discharge outcomes for older adult patients with heart failure and their family caregivers. This model emphasizes enhanced communication and collaboration between healthcare professionals, patients, and their caregivers. Nurses and social workers involved in the intervention participated in specialized educational programs focused on effectively engaging patients and caregivers in the discharge planning process. As part of the intervention, patients and their family caregivers completed questionnaires to assess their needs upon discharge, watched an educational video on post-discharge care management, and received comprehensive information about accessing relevant community-based services.
Compared to a control group receiving standard discharge care, older adults and caregivers in the intervention group reported feeling significantly better prepared to manage care at home after discharge. Furthermore, at a two-week follow-up post-discharge, caregivers in the intervention group reported greater satisfaction with their caregiving roles than those in the control group. This model underscores the value of actively involving patients and families in discharge planning and providing them with the knowledge, skills, and resources needed for successful transitions.
Take-Home Messages on Intra-Hospital and Community Transitions
- Significant gaps in care during critical transitions, both within hospitals and from hospital to community settings, can lead to adverse events, unmet patient and caregiver needs, low satisfaction with the care experience, and increased hospital readmission rates.
- A growing body of research supports promising innovations aimed at improving the quality of care for chronically ill older adults during these critical transition points.
- While family caregivers play a vital role in supporting older adults through healthcare transitions, more rigorous research is needed to fully understand and measure their specific roles, needs, and the impact of transitional care interventions on their well-being. Nurses and social workers are essential in collaborative efforts to advance the science and practice in this critical area of healthcare.
Transitions To and From Acute Care Hospitals: Bridging the Gap
Studies have evaluated various multidimensional transitional care models specifically designed to address the common challenges that arise during the handoff of chronically ill patients between acute care hospitals and their homes or other community settings. Nurse-led interdisciplinary interventions have consistently demonstrated improvements in both the quality of care delivered and cost savings associated with care transitions. These models focus on proactive planning, patient education, and ongoing support to ensure a smoother and safer transition from hospital to home.
Care Transitions Coaching
A multidisciplinary team at the University of Colorado Health Sciences Center in Denver developed and tested a “Care Transitions Coaching” intervention. This model is designed to empower older patients and their family caregivers to take a more active and informed role during care transitions. An advanced practice nurse (APN) served as the “transitions coach,” providing personalized education and skills training to patients and caregivers. The coaching focused on essential skills needed to promote continuity of care across different healthcare sites and settings. Coaching sessions began while the patient was still in the hospital and continued for 30 days after hospital discharge, providing ongoing support during the critical post-discharge period.
A randomized controlled trial assessed the effectiveness of this coaching intervention. Results showed that patients who received care transitions coaching had significantly lower all-cause hospital readmission rates within 90 days post-discharge, compared to a control group receiving standard discharge care. Furthermore, at six-month follow-up, mean hospital costs were approximately $500 less for patients in the intervention group, demonstrating both improved outcomes and cost-effectiveness of the care transitions coaching model.
Advanced Practice Nurse (APN) Transitional Care Model
Since 1989, a multidisciplinary team at the University of Pennsylvania has been developing, testing, and refining an innovative APN-led transitional care model. This model targets high-risk, cognitively intact older adults with a range of medical and surgical conditions who are transitioning from hospital to their homes. The APN takes primary responsibility for optimizing each patient’s health throughout their hospitalization and for developing a comprehensive plan for post-discharge care, working collaboratively with the older adult, their family caregiver, physician, and other members of the healthcare team, and guided by evidence-based protocols. Crucially, the same APN who manages care in the hospital also implements the post-discharge care plan. This is achieved through traditional visiting nurse services, home visits, and ongoing telephone availability seven days a week, ensuring consistent support and a single point of contact for patients and families.
Three randomized controlled trials, funded by the National Institutes of Health (NIH), have consistently demonstrated the significant benefits of this APN transitional care model. These studies have shown that the model improves older adults’ satisfaction with their care, reduces hospital readmissions, and decreases overall healthcare costs. Current research is further investigating the model’s specific effects on family caregivers, recognizing their crucial role in the success of transitional care.
The most recent trial of this APN-directed protocol focused on older adults experiencing acute episodes of heart failure. Compared to a control group, patients in the intervention group demonstrated improved physical function, enhanced quality of life, and greater satisfaction with their care. Importantly, the intervention group also experienced fewer hospital readmissions during the year following discharge, resulting in a mean savings in total healthcare costs of $5,000 per patient. Ongoing NIH-funded clinical trials are currently exploring the benefits of this APN-led model for cognitively impaired older adults and their family caregivers, further expanding the applicability and impact of this innovative approach.
Limitations of Current Evidence in Transitional Care
While family caregivers are often recognized as important stakeholders in transitional care interventions, they have frequently not been directly enrolled as study subjects in research evaluating these models. Instead, the focus has primarily been on the older adults receiving care. Consequently, there is a relative scarcity of evidence specifically examining how these transitional care innovations directly impact caregiver outcomes, such as caregiver burden, well-being, and satisfaction.
Furthermore, the majority of evaluated transitional care models have centered on nurse-directed interventions. While social workers are acknowledged as collaborators in some models, the unique and distinct contributions of social workers within these interdisciplinary teams have not been extensively studied or quantified. Social work professionals bring valuable expertise in areas such as patient and family empowerment, psychosocial assessment, resource mobilization, and addressing the broader social determinants of health. Further research is needed to specifically identify and evaluate the distinct roles and contributions of social workers in leading or partnering within transitional care models, and to understand how their expertise can enhance the effectiveness and comprehensiveness of these programs.
To date, a significant portion of research in transitional care has focused on the transition of older patients from the hospital setting back to their homes. There is a recognized need for more research to investigate transitions to and from other care settings, such as skilled nursing facilities (SNFs). This is a critical area for future research, as an increasing number of older adults experience multiple transitions across various healthcare settings during the course of an illness. These multiple transitions can lead to fragmented care and adverse consequences, such as serious adverse events related to medication errors and lack of coordination. Data indicates a significant rise in the percentage of hospitalized Medicare patients discharged to skilled nursing facilities, highlighting the importance of understanding and improving transitions involving SNFs. Moreover, concerns have been raised about increasing rehospitalization rates among nursing home residents, further emphasizing the need for targeted transitional care strategies for this population.
Implications for Enhanced Support of Family Caregivers in Transitional Care
Although many existing studies on transitional care have not explicitly focused on family caregivers, the available evidence offers valuable insights into key elements that can improve care transitions and, importantly, enhance support for family caregivers within these programs. These key elements include:
- Patient- and Family-Centered Approach: Prioritizing the individual needs, preferences, and goals of both patients and their family caregivers in the design and delivery of transitional care services. This requires active listening, shared decision-making, and tailoring interventions to meet the unique circumstances of each patient-caregiver dyad.
- Interdisciplinary Team Approach Guided by Evidence-Based Protocols: Utilizing interprofessional teams, including nurses, social workers, physicians, pharmacists, and other relevant healthcare professionals, working collaboratively and guided by established evidence-based protocols and best practices for transitional care.
- Improved Communication Among Patients, Family Caregivers, and Providers: Establishing clear, consistent, and effective communication channels and strategies to facilitate seamless information exchange and coordination among all members of the care team, including patients and their family caregivers. This includes providing information in accessible formats, actively soliciting and addressing questions and concerns, and ensuring shared understanding of care plans and goals.
- Leveraging Information Technology and Electronic Health Records: Utilizing information systems, such as interoperable electronic medical records (EHRs), that can seamlessly span across different healthcare settings and providers. This facilitates efficient information sharing, reduces redundancy, and improves care coordination during transitions.
Evidence-Based Family-Focused Care Strategies
Research findings consistently indicate that family caregivers’ lack of adequate knowledge, skills, and access to resources are significant barriers to effective care transitions and successful home management of complex health conditions. Family caregivers often face challenges in recognizing early warning signs of health deterioration in older adults, and may lack the skills to manage complex medication regimens, wound care, or other medical needs. Furthermore, they may struggle to navigate the healthcare system and access timely support from healthcare professionals when questions or concerns arise.
To effectively address these barriers and enhance family caregiver support within transitional care, new investments and targeted strategies are essential. A comprehensive assessment of each caregiver’s individual needs, strengths, and challenges should be conducted at the time of the older adult’s admission to the hospital or entry into a transitional care program. This requires equipping healthcare professionals with specialized tools and dedicated time to provide tailored coaching, education, and support to family caregivers, preparing them for their crucial roles during and after healthcare transitions.
Development of Performance Measures for Family Caregiver Support
One of the most significant clinical barriers to achieving high-quality transitional care that effectively supports family caregivers is the current lack of standardized performance measures that specifically capture their roles in care coordination, continuity, and the overall transition process. Most existing healthcare performance standards primarily focus on processes and outcomes within individual care settings (e.g., hospitals, home health agencies) rather than across the continuum of care. Few performance measures currently assess the actual experiences of older adults and their family caregivers during healthcare transitions, and virtually none explicitly recognize and measure the distinct contributions and needs of family caregivers in this context.
Designing, rigorously testing, and integrating performance measures that specifically address family caregiver support into national performance measurement sets is a high priority. These measures are essential for driving quality improvement efforts, promoting accountability, and ensuring that transitional care programs are effectively meeting the needs of both patients and their family caregivers. Such measures could include assessments of caregiver preparedness, caregiver burden, caregiver satisfaction with communication and support, and patient-reported outcomes related to caregiver involvement in care transitions.
Regulatory Reform to Facilitate Patient- and Family-Centered Transitional Care
Current Medicare regulations and healthcare financing structures often inadvertently promote a fragmented system of separate and distinct providers – hospitals, home health care agencies, and skilled nursing facilities – each delivering and billing separately for acute care services. This system, with its emphasis on episodic care and fee-for-service reimbursement, often pays insufficient attention to the ongoing and continuing care needs of older adults and their family caregivers as they move across these various settings. This can result in significant gaps in care coordination and a lack of seamless transitions.
Regulatory barriers that impede the delivery of evidence-based transitional care models, which are designed to focus comprehensively on both patients and their family caregivers, must be identified and eliminated. Policy changes are needed to incentivize collaboration, care coordination, and integrated service delivery across healthcare settings. This includes exploring bundled payment models, accountable care organizations, and other innovative payment mechanisms that reward value-based care and prioritize seamless transitions.
Aligning Financial Incentives Through Reimbursement Policies
In the current fee-for-service healthcare system, nurses, social workers, physicians, and other healthcare providers are generally not adequately reimbursed for the time and effort involved in care coordination and transitional care services. Instead, the reimbursement structure often inadvertently incentivizes hospitals for providing acute care, as it fills hospital beds and generates revenue. This can contribute to frequent transitions to and from acute care facilities, potentially without adequate attention to preventive care and community-based support.
Public and private payers need to adopt more flexible and value-based reimbursement policies that appropriately compensate healthcare providers for care coordination, transitional care services, and proactive patient and family engagement. Developing and testing financial incentives that explicitly support family caregivers and improve the transitions between levels of care and across different healthcare settings is crucial. This could include reimbursement for caregiver training and education, respite care services, and telehealth-based support for caregivers. Aligning financial incentives with the goals of patient-centered, coordinated, and high-quality transitional care is essential to drive system-wide improvements and ensure that both patients and their family caregivers receive the support they need.
The Ongoing Need for Further Research in Transitional Care
While significant progress has been made in developing and evaluating transitional care models, few evidence-based models explicitly and comprehensively focus on addressing the specific needs of family caregivers during acute care transitions. Furthermore, the quality and rigor of the available evidence from existing transitional care model evaluations are somewhat uneven across studies. There remains a critical need for more rigorous, well-designed studies that directly compare the benefits, costs, and effectiveness of promising transitional care innovations, particularly those that incorporate robust family caregiver support components.
The available evidence strongly suggests that nurses play pivotal roles in ensuring successful care transitions and improving patient outcomes. However, further research is needed to rigorously evaluate the value and impact of interventions led by social workers, as well as collaborative interventions led by interdisciplinary teams of nurses and social workers. Understanding the unique and synergistic contributions of different healthcare professionals within transitional care teams is essential to optimize model design and implementation, and to ensure that these programs effectively address the complex needs of older adults and their family caregivers during vulnerable transition periods.
Acknowledgments
Mary Naylor is Marian S. Ware professor in gerontology at the University of Pennsylvania in Philadelphia. She is working on an NIH-funded clinical trial of APN-managed transitional care for cognitively impaired older adults and their family caregivers (grant 5-R01-AG023116-02). Stacen A. Keating is a postdoctoral fellow at the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.
Footnotes
The authors of this article have disclosed no other significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity
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