Effective Transitions between Care Settings

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Maureen Stefanides wanted to honor her father’s last wish: to die at home. She was unsuccessful. Before his passing, her father frequently transferred in and out of hospitals and nursing homes, causing needless suffering from pressure sores, recurrent infections, and malnutrition. It robbed him of his dignity and quality of life.

This family caregiver’s personal account captured public attention in a New York Times expose.1 Unfortunately, heartbreaking accounts such as this one are heard all too often. Unnecessary and avoidable care transitions can result in adverse outcomes, especially among older adults and people with multiple chronic conditions. Concerns about care transitions between acute and long-term services and supports (LTSS) settings have been raised since at least the 1990s.

More recently, studies have emphasized the growing need to address care transitions from nursing homes to community-based settings, as well as to divert people from nursing homes.2,3,4 Smooth care transitions are at the core of good health care practice and person- and family-centered care. Improving effective care transitions could require coordinating nonmedical services, such as educating family caregivers, accessing appropriate community-based services, and ensuring access to transportation. Providers need to avoid unnecessary transitions and ensure smooth coordination of necessary transitions, particularly from hospitals.

What Are Care Transitions?

Care transitions occur when people move between one care setting or provider to another; for example, from home to hospital, hospital to home, or nursing home to hospital.

How Can States Measure and Improve Effective Transitions?

The second edition (2014) of the AARP LTSS Scorecard is an excellent tool for measuring state progress in care transitions.5 The ability to measure care transitions is new. There were insufficient data for the first Scorecard (2011) to measure the extent to which LTSS is effectively coordinated or integrated with health-related services and social supports. Six Scorecard indicators measure state performance on two types of transitions. The first four indicators focus on minimizing disruptive transitions between care settings. The last two indicators measure the relative success of states to transition people from nursing homes back to the community. Here are the measures and pertinent questions to answer:

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