title: Regardless of age: Incorporating principles from geriatric medicine to improve care transitions for patients with complex needs.
abstract: With its focus on holistic approaches to patient care, caregiver support, and delivery system redesign, geriatrics has advanced our understanding of optimal care during transitions. This article provides a framework for incorporating geriatrics principles into care transition activities by discussing the following elements: (1) identifying factors that make transitions more complex, (2) engaging care "receivers" and tailoring home care to meet patient needs, (3) building "recovery plans" into transitional care, (4) predicting and avoiding preventable readmissions, and (5) adopting a palliative approach, when appropriate, that optimizes patient and family goals of care. The article concludes with a discussion of practical aspects of designing, implementing, and evaluating care transitions programs for those with complex care needs, as well as implications for public policy.
authors.affiliation: Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University, Mason F. Lord Building, Center Tower, 5200 Eastern Avenue, 7th Floor, Baltimore, MD, 21224, USA, aarbaje@jhmi.edu.
authors.forename: Alicia I
authors.initials: AI
authors.lastname: Arbaje
authors.forename: Devan L
authors.initials: DL
authors.lastname: Kansagara
authors.forename: Amanda H
authors.initials: AH
authors.lastname: Salanitro
authors.forename: Honora L
authors.initials: HL
authors.lastname: Englander
authors.forename: Sunil
authors.initials: S
authors.lastname: Kripalani
authors.forename: Stephen F
authors.initials: SF
authors.lastname: Jencks
authors.forename: Lee A
authors.initials: LA
authors.lastname: Lindquist
mesh_terms: D000359:Aftercare / Q000379:methods / Q000458:organization & administration; D000368:Aged; D017028:Caregivers / Q000193:education; D002908:Chronic Disease / Q000628:therapy; D003256:Community Participation; D015897:Comorbidity; D003266:Continuity of Patient Care / Q000458:organization & administration*; D005260:Female; D006291:Health Policy; D006299:Health Services for the Aged / Q000458:organization & administration*; D006801:Humans; D057187:Independent Living / Q000193:education; D008297:Male; D017063:Outcome Assessment, Health Care; D010347:Patient Care Planning; D010351:Patient Discharge / Q000592:standards*; D018802:Patient-Centered Care / Q000458:organization & administration; D011314:Preventive Health Services / Q000379:methods / Q000458:organization & administration; D058996:Quality Improvement; D014481:United States