Care Transitions
Because of the heterogeneity of the older adult population, more research is needed to develop measures for older adults with a wide range of medical conditions.
ED visits are often critical inflection points in an older adult’s health trajectory. A large amount of evidence indicates that an ED visit is a period of vulnerability for older adults, especially as they transition back to the community, from the ED to home or a nursing home. Thus, improving management of care transitions could improve person-centered care, increase value, and reduce health care costs. The GEAR subcommittee on care transitions defined care transitions as “the movement of patients between the ED and home or another care setting” and noted that care transitions can be bidirectional.
Best Practice Notes
- Bridge interventions, or interventions with at least two touch points, were more effective than those focused on a single point.
- Patients, families, caregivers, and health care providers should be included in selecting outcomes of interest and describing their satisfaction with an intervention.
Top Research Priority Areas
- What are the optimal outcome measures for ED to home transition interventions (i.e. appropriate for a heterogeneous population and responsive to change)? Best timing, process, utilization, patient perspective battery of measures?
- Who are the optimal candidates for additional support during the ED to home transition? Are these the same as patients as those at highest risk of ED return (much more existing research on this question)?
- How can we improve information transfer/communication in bidirectional NH-ED transitions?
- Can we link data from ED on social risk factors, fall risk, med safety, physical function to improve transition interventions rather than just care coordination?
- How can we best incorporate stakeholder perspectives in ED transitions research?