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Care Transitions

Toward the end of a hospitalization, transition plans are made to discharge patients into appropriate settings. While some older patients will require nursing home care, others will be able to return to their homes and communities. Hospital lengths of stay, cost of care, readmissions to hospitals and mortality can be reduced and quality of life and patient satisfaction can be improved for patients who receive appropriate discharge planning or transitional care (Cochrane Collaboration, 2010; Naylor et al., 2004).  

In facilitating the return of older adults into the community, there are many helpful models to use to consider the most effective ways to proceed.  In addition, practice and research have identified potential barriers to and challenges for success. The resources below can help those in discharge planning roles make effective plans for reintegration back into the community.   

Challenges & Barriers to Effective Care Transition

Discharge Planning and Preparation

Assessment of Older Adult

Assessment of the Family Caregiver

Components of Successful Care Transitions



Medication Reconciliation and Management

Follow-up Plan

Self-management Support National

Self-management Support Atlanta Region

Measuring Satisfaction with Transitional Care

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