TRANSITIONAL CARE

Mary Naylor
University of Pennsyivania

Stacen A. Keating
University of Pennsyivania

TRANSITIONAL CARE encompasses a broad range (Harrison et al., 2002; Levine, 1998; Weaver et
of services and environments designed to pro- al., 1998), and high rehospitalization rates
mote the safe and fimely passage of patients (Bernstein et al, 2004; Naylor, 2003; Vinson et
between levels of health care and across care al., 1990).
setfings (Coleman & Boult, 2003; Naylor, Many factors contribute to gaps in care
2003). High-quality transifional care is espe- during critical transifions (Naylor, 2003). Poor
cially important for older adults with mulfiple communication, incomplete transfer of infor-
chronic condifions and complex therapeufic mafion, inadequate educafion of older adults
regimens, as well as for their family care- and their family caregivers, limited access to
givers. These pafients typically receive care essenfial services, and the absence of a single
from many providers and move frequently point person to ensure continuity of care all
within health care settings (Agency for contribute. Language and health literacy is-
Healthcare Research and Quality, 2001; Burt & sues and cultural differences exacerbate the
McCaig, 2001; Gabrel & Jones, 2000; Part- problem (Naylor, 2003). (See "Culturally
nership for Solufions, 2002). A growing body Appropriate Care" for more about culture's
of evidence suggests that they are parficularly effects on health care.)
vulnerable to breakdowns in care and thus Family caregivers play a major—and per-
have the greatest need for transifional care haps the most important—role in supporting
services (Coleman et al., 2004a; Naylor, 1999, older adults during hospitalizafion and espe-
2000, 2004). Poor "handoff" of these older cially after discharge. Unfil recently, however,
adults and their family caregivers from hospi- little attenfion was paid to family caregivers'
tal to home has been linked to adverse events disfincfive needs during transitions in care.
(Forster et al., 2003; Moore et al., 2003; Wenger Consequently, family caregivers consistently
& Young, 2007), low safisfacfion with care rate their level of engagement in decision

Joumal of Social Work Education, Vol. 44, No. 3 (Fall 2008); Supplement.
Copyright © 2008, Council on Social Work Education, Inc. Aii rigiits reserved. 65
66 JOURNAL OF SOCIAL WORK EDUCATION

making about discharge plans and the quality target family caregivers. Descripfions of two
of their preparafion for the next stage of care models for each of the three categories follow.
as poor (Levine et al, 2006).
Caregiving can be rewarding, but it can Community-Based Care
also impose burdens on family caregivers Evaluafions of federal, state, and provider
(Schumacher et al., 2006). The stress of caregiv- inifiafives designed to improve the continuity
ing is likely to be exacerbated during episodes of care for high-risk older adults indicate
of acute iUness. Nurses and social workers that having increased access to short-term,
need to attend to the emotional needs of care- community-based services for managing
givers during transitional care to help mirü- acute episodes of chronic illnesses would like-
mize their negative experiences and to enhance ly be of benefit (Abdallah, 2005; Kane et al.,
their ability to support their loved ones. 2004; Kodner & Kyriacou, 2003). The findings
of these studies have informed the design of
Research-Based Innovations community-based transitional care models in
To understand the state of the science related the United States.
to transifional care models for older adults in Hospital at home. The needs of older adults
the United States and the roles of family care- who commonly experience acute episodes of
givers in these models, the authors searched chronic condifions may be best addressed by
the Medline, CINAHL, and Social Work home-based care models such as Hospital at
Abstracts databases using combinafions of the Home. (See [Link] for more
following terms: research, ages 65 years or informafion.) Pafient, family caregiver, and
older, continuity of patient care, pafient trans- provider perspecfives on the benefits and lim-
fer, discharge planning and postdischarge itafions of this approach need to be examined.
follow-up, and transitional care. The search Leff and colleagues enrolled community-
period was from 1996 to 2007. dwelling, chrorücally ill older adults who
The search identified three promising would otherwise have been hospitalized for
approaches to improving the quality of care an acute exacerbation of selected chronic con-
for chronically ill older adults: difions in a prospecfive, quasi-experimental
study (that is, a study lacking randomization).
• increasing older adults' access to proven Eligible patients were idenfified in the ED and
community-based transiüonal care services discharged to home after enrollment, where
• improving transitions within acute hospi- they received nursing, physician, and other
tal settings services as guided by a prescribed protocol.
• improving patient handoffs to and from The clinical outcomes achieved were similar
acute care hospitals to those obtained with acute care in the hospi-
tal and resulted in shorter lengths of stay and
In general, these approaches have focused reduced overall costs (Leff et al., 2005). Older
explicitly on the pafient and only implicitly adults expressed satisfaction with the treat-
 TRANSITIONAL CARE 67

ment they received in the program (Leff et al., astating effects on the health of older adults
2006). and the well-being of family caregivers. For
Day hospital. Modeled after a program example, serious medication errors are com-
offered in the British health care system, the mon during transition periods (Foust et al.,
day hospital is another form of community- 2005). The following hospital-based transi-
based transitional care. The Collaborative As- tional care models are designed to address
sessment and Rehabilitation for Elders this problem.
(CARE) program at the University of Penn- Acute Care for Elders (ACE). The ACE
sylvania in Philadelphia was one such initia- model, developed at the University Hospitals
tive (Harrison et al., 2002; Neff et al., 2003). of Cleveland in Ohio, aims to avoid functional
The CARE program operated as a Medicare- decline and improve discharge readiness
certified comprehensive outpatient rehabilita- among older adults. Features of the model
tion facility (CORF; Evans «& Yurkow, 1999). include adapting the physical environment to
This interdisciplinary program, directed by a meet the older adult's needs, holding daily in-
geriatric NP, targeted community-based older terdisciplinary team conferences, using nurse-
adults who were at high risk for hospitaliza- initiated guidelines for preventive and re-
tion and other adverse outcomes. EnroUees storative care, and starting discharge planning
had access to a range of health, palliative, and at admission and actively including family
rehabilitation services for a few days each members in it (Panno et al., 2000). An early
week for up to nine weeks (Evans & Yurkow). randomized, controlled trial demonstrated
A quasi-experimental study revealed im- that ACE patients had higher levels of function
proved function and decreased hospital use at discharge, shorter lengths of hospital stay,
among the patients in the CARE program (Yu and decreased hospital costs compared with
et al., 2005). There were no differences in out- patients receiving usual care (Panno et al.).
comes between cognitively intact and cogrü- Professional-patient partnership. This model
tively impaired older adults, suggesting that was used in Baltimore to improve discharge
this challenging latter group also benefited planning and outcomes for older adult patients
from these services (Yu et al.). Unfortunately, with heart failure and their family caregivers
changes in reimbursement of CORFs forced (Bull et al., 2000). Nurses and social workers
the program to close (Evans et al., 1995; Evans participated in an educational program that
& Yurkow). This model's effects on the needs emphasized engaging the patient and caregiv-
and outcomes of family caregivers should be er in the discharge planning process. Patients
studied. and their family caregivers completed a ques-
tionnaire to assess their needs upon discharge,
Transitions Within Settings
watched a videotape on postdischarge care
Frequent transitions within a hospital, such as management, and received information on
from the ED to an ICU to a step-down unit to accessing community services. When com-
a general medical-surgical unit, can have dev- pared with older adults and caregivers in a
68 JOURNAL OF SOCIAL WORK EDUCATION

matched control hospital, study participants sity of Pennsylvania has been testing and re-
reported feeling better prepared to manage fining an innovative model of transitional care
care after discharge. Two weeks postdis- delivered by APNs. Patients offered this care
charge, caregivers in the intervention group are high-risk, cogrütively intact older adults
were more satisfied with their roles than peers with a variety of medical and surgical condi-
in the control group were (Bull et al.). tions who are transitioning from hospital to
home. In collaboration with each older adult,
Transitions to and From Acute Care family caregiver, physician, and other health
Hospitais team members and guided by evidence-based
Studies have evaluated multidimensional protocols, the APN assumes primary responsi-
models of transitional care designed to bility for optimizing each patient's health dur-
address problems that commonly occur dur- ing hospitalization and for desigiüng the plan
ing the handoff of chronically ill patients for follow-up care. The same nurse imple-
between hospital and home. Nurse-led inter- ments this plan after discharge by providing
disciplinary interventions have consistently traditional visiting nurse services, making
improved quality and cost savings (Coleman home visits and being available seven days a
et al., 2004b, 2006; Naylor et al., 1999, 2004; week by telephone. Three randomized, con-
Rich et al., 1995). trolled trials funded by the National Institutes
Gare transitions coaching. A multidiscipli- of Health (NIH) consistently demonstrated
nary team at the University of Colorado that this model of care improves older adults'
Health Sciences Center in Denver tested an satisfaction, reduces rehospitalizations, and
intervention designed to encourage older decreases health care costs (Naylor et al., 1994,
patients and their family caregivers to assume 1999, 2004). Study is now focusing on the
more active roles during care transitions. An model's effects on caregivers.
advanced practice nurse (APN) served as the The most recently reported trial of a pro-
"transitions coach," teaching the patient and tocol directed by APNs is designed to address
caregiver skills needed to promote cross-site the health problems and risks common among
continuity of care. Coaching began in the hos- older adults during an acute episode of heart
pital and continued for 30 days after dis- failure. When compared with the control
charge. A randomized, controlled trial foimd group, members of the intervention group
that patients who received this intervention have improved physical function, quality of
had lower all-cause rehospitalization rates life, and satisfaction with care. People in the
through 90 days after discharge compared intervention group had fewer rehospitaliza-
with control patients. At six months, mean tions during the year after discharge, resulting
hospital costs were approximately $500 less in a mean savings in total health care costs of
for patients in the intervention group com- $5,000 per patient (Naylor et al., 2004).
pared with controls (Coleman et al., 2006). One of the authors, MN, is currently
APN transitional care model. Since 1989, a working as part of a multidisciplinary team
multidisciplinary team based at the Univer- on an ongoing NIH-funded clinical trial that is
 TRANSITIONAL CARE 69

testing the benefits of this model of care for errors. The percentage of hospitalized Med-
cognitively impaired older adults and their icare patients who were referred to a skilled
family caregivers. nursing facility from the hospital rose signifi-
cantly from 37.4% in 1986 to 46% in 1999 (Sil-
Limitations of the Evidence verstein et al, 2006). Stephen Jencks, MD, the
Although caregivers often have been included former senior clinical advisor at the Centers
as targets of tested interventions, they typical- for Medicaid and Medicare Services, told MN
ly have not been enrolled in studies; rather, that the rehospitalization rate among nursing
the study subjects have been the older adults home residents at 30 days increased by 50%
receiving care. Thus, there is limited evidence between 2000 and 2004.
about how these innovations affect caregiver
outcomes. Implications for Support of Family
Most models have assessed nurse- Caregivers
directed interventions. Social workers were Although they have had limited focus on fam-
identified as collaborators in some models, ily caregivers, the available studies indicate
but the unique contributions of social workers that the following are key elements to improv-
have not been identified. Social workers have ing care transition and enhancing the support
long acknowledged the importance of collab- of family caregivers:
oration, autonomy, and empowerment of
patients and their families. These profession- • focus on the patients' and family care-
als contribute knowledge and expertise of givers' needs, preferences, and goals
many aspects of care, including the effects that • utilize interdisciplinary teams guided by
transitional care has on families beyond phys- evidence-based protocols
ical ailments and the need for clear communi- • improve communication among patients,
cation among patients, caregivers, and health family caregivers, and providers
care providers (Zimmerman & Dabelko, • use information systems, such as elec-
2007). Studies are needed to make the case for tronic medical records, that can span tra-
social workers to serve as leaders or partners ditional settings
in transitional care models.
To date, most research has focused on the Evidence-Based Family-Focused Care
transition of older patients from hospital to Study findings suggest that family caregivers'
home. More research is needed on transition lack of knowledge, skills, and resources are
to and from settings such as skilled nursing significant barriers to effective care (Brodaty
facilities (Nishita et al, 2008). Research in this et al., 2003). Early identification and treatment
area is critical because increasing numbers of of an older adult's health problems are
older adults are experiencing multiple transi- beyond the skills of family caregivers, and
tions during the course of an illness, often they often lack access to a health professional
with devastating consequences such as seri- who will respond to questions and concerns
ous adverse events related to medication in a timely manner (Kelley et al., 1999).
70 JOURNAL OF SOCIAL WORK EDUCATION

To address these barriers, new invest- Alignment of Incentives Through

ments are needed to prepare family caregivers Reimbursement
for their roles during critical transifions. A
comprehensive assessment of each caregiver's Nurses, social workers, physicians, and other
needs should be performed at the fime of the providers are not reimbursed for coordinating
older adult's admission to the hospital, which care in the fee-for-service system. Instead, the
will require that health professionals have reimbursement policy favors hospitals for
new tools and more fime for coaching family providing acute care because it fills empty
caregivers. beds and generates revenue. The result is fre-
quent transifioning to and from acute care
Development of Performance
facilifies. Public and private payers need to be
Measures
moreflexibleabout reimbursement, adequate-
One of the most significant clinical barriers to ly compensate health care providers for care
high-quality care that supports family care- coordination and transifional care, and devel-
givers during challenging transifions is the op and test incenfives that support family
dearth of performance measures that capture caregivers and improve the transifion be-
their roles in care coordinafion, continuity, tween levels of care or across settings.
and transition. Most existing standards focus
on processes and outcomes within, rather Need for Research
than across, settings. Few focus on the actual Few evidence-based transifional care models
experiences of older adults during transfers, explicitly focus on the needs of family care-
and none recognize the distinct role of family givers during acute care transifions. Further-
caregivers. Designing, testing, and integrating more, the quality of the available evidence
such measures into national performance sets from these models is uneven. Rigorous stud-
are high priorifies. ies comparing the benefits and costs of prom-
ising innovafions are needed.
Regulatory Reform
The available evidence suggests that
Medicare regulafions promote the system of nurses play pivotal roles in ensuring that suc-
separate and distinct providers—hospitals, cessful care transifions occur. Similar studies
home health care agencies, and skilled nursing of the value of intervenfions led by social
faciUfies—delivering, monitoring, and charg- workers and by nurse and social worker
ing for acute care services. A system that pays teams are needed.
little attenfion to the continuing care needs of
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Mary Naylor is Marian S. Ware Professor in Gerontology at the University of Pennsylvania in Phil-
adelphia. Stacen A. Keating is a postdoctoral feilow at the Center for Health Outcomes and Policy
Research at the University of Pennsylvania School of Nursing.

Reprinted with permission fronn the American Journal of Nursing. This article was first published as a
supplement to the September 2008 issue of the American Journal of Nursing. Continuing education
contact hours are available to nurses at [Link]/ajnfamilycaregivers.

Address correspondence to iVlary Naylor, naylor@[Link].