title: Transitions of elders between long-term care and hospitals.
abstract: Elderly long-term care recipients who require acute hospitalizations must navigate a fragmented system with poor "handoffs," often resulting in negative outcomes. This article makes the case that reducing preventable hospitalizations and improving transitions to and from hospitals will enhance health care quality and outcomes among these elders. Immediate action targeting diffusion of evidence-based care is recommended to decrease avoidable rehospitalizations and achieve cost savings. Policy changes are needed to address barriers to high-quality transitional care, including deficits in health professionals' and caregivers' knowledge and resources, regulatory obstacles, and inadequate financial incentives and clinical information systems.
authors.affiliation: University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Mary D
authors.initials: MD
authors.lastname: Naylor
authors.forename: Ellen T
authors.initials: ET
authors.lastname: Kurtzman
authors.forename: Mark V
authors.initials: MV
authors.lastname: Pauly
mesh_terms: D000368:Aged; D003144:Communication Barriers; D003266:Continuity of Patient Care / Q000458:organization & administration*; D055317:Evidence-Based Practice / Q000458:organization & administration; D018166:Health Care Reform; D006291:Health Policy; D006301:Health Services Needs and Demand; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008134:Long-Term Care / Q000458:organization & administration*; D009735:Nursing Homes / Q000458:organization & administration*; D017063:Outcome Assessment, Health Care; D010351:Patient Discharge; D010360:Patient Transfer / Q000458:organization & administration*; D018802:Patient-Centered Care; D017749:Total Quality Management / Q000458:organization & administration*; D014481:United States