title: Review of current conceptual models and frameworks to guide transitions of care in older adults.
abstract: Older adults are at high risk for gaps in care as they move between health care providers and settings during the course of illness, such as following hospital discharge. These gaps in care may result in unnecessary re-hospitalization and even death. Nurses can assist older adults to achieve successful transitions of care by taking a systematic approach and individualizing care to meet patient and family health literacy, cognitive, and sensory needs. This article reviews trends in transitions of care, models, partnerships, and health literacy. Models described include the Transitional Care Model, Care Transitions Program, Project BOOST (Better Outcomes for Older adults through Safe Transitions), Project RED (Re-engineered Discharge), Chronic Care Model, and INTERACT(II) (Interventions to Reduce Acute Care Transfers). Approaches to transitions of care are discussed, and resources for geriatric nurses are provided.
authors.affiliation: College of Nursing, University of Arkansas for Medical Sciences, 4301 West Markham, Slot #529, Little Rock, AR 72205, USA. Electronic address: caenderlin@uams.edu.
authors.forename: Carol A
authors.initials: CA
authors.lastname: Enderlin
authors.affiliation: Gerontology, University of Utah, College of Nursing, 10 South 2000 East, Salt Lake City, UT 84112, USA.
authors.forename: Nanci
authors.initials: N
authors.lastname: McLeskey
authors.affiliation: College of Nursing, University of Arkansas for Medical Sciences, 4301 West Markham, Slot #529, Little Rock, AR 72205, USA.
authors.forename: Janet L
authors.initials: JL
authors.lastname: Rooker
authors.affiliation: Nebraska Methodist College of Nursing and Allied Health, 720 North 87th Street, Omaha, NE 61884, USA.
authors.forename: Colleen
authors.initials: C
authors.lastname: Steinhauser
authors.affiliation: Northeastern University, Bouve College of Health Sciences, School of Nursing, 106 C, 360 Huntington Avenue, Boston, MA 02115, USA.
authors.forename: Deborah
authors.initials: D
authors.lastname: D'Avolio
authors.affiliation: United Health Care, House Calls Program, Little Rock, AR, USA.
authors.forename: Riesa
authors.initials: R
authors.lastname: Gusewelle
authors.affiliation: School of Nursing, College of Health and Human Services, University of North Carolina Wilmington, Wilmington, NC, USA.
authors.forename: Kathleen A
authors.initials: KA
authors.lastname: Ennen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care; D016330:Frail Elderly; D057220:Health Literacy; D006801:Humans; D017146:Models, Organizational; D014481:United States