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Transitions of Elders Between
Long-Term Care and Hospitals
Mary D. Naylor, PhD, RN
Marian S. Ware Professor in Gerontology
University of Pennsylvania School of Nursing
Author Contact:
420 Guardian Drive
Philadelphia, PA 19104-6096
Tele: 215-898-6088
Fax: 215-573-4225
Email: naylor@nursing.upenn.edu
Acknowledgement: Paper commissioned for “Building Bridges: Making a Difference in LongTerm Care” AcademyHealth Colloquium sponsored by The Commonwealth Fund. Presented at
2007 Policy Seminar, February 14, 2007, Washington, D.C.
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Abstract
Elderly long term care (LTC) recipients who require acute care services must navigate a
system characterized by gaps in care and poor “hand-offs”, often resulting in negative outcomes.
This paper makes the case that health care quality among these elders may be enhanced by (1)
avoiding preventable hospitalizations and (2) improving transitions to and from hospitals when
such transfers are needed. Health care policy changes to prevent avoidable hospitalizations and
to enhance necessary care transitions between LTC and acute care hospitals are suggested.
Research priorities to inform future changes in standards of care for this population are
recommended.
Key Words: transitions, long term care; acute hospital care; frail elders
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Introduction
Long term care (LTC) encompasses a broad set of health, social, and environmental
programs and services provided to older adults for a prolonged period in a range of settings
including elders’ homes, assisted living facilities [ALFs], and nursing homes [NHs].[1, 2] These
typically low-tech services are designed to help elders cope with physical, functional and
cognitive deficits associated with multiple chronic illnesses and major disabilities, function as
independently as possible and maintain a high quality of life. [1-3] Family caregivers often play a
central role in decision making regarding these services.[1-3] In contrast, acute care
hospitalizations are characterized by short term, high-tech medical services designed to treat
acute illnesses or major injuries. [2] Family caregivers generally have limited involvement in
decision making during episodes of acute hospital care.[4]
The more vulnerable elderly LTC recipients often require acute hospital services. These
‘at risk’ older adults frequently move among components of the health care system that have
vastly different goals and cultures with few bridges to connect them. Consequently, their
transitions are frequently characterized by serious breakdowns in communication and gaps in
care that have negative human and economic consequences.
Building on emerging insights about the needs of frail elders who often require acute
services, clinical and health services researchers have tested care innovations designed to
enhance the quality of care and outcomes for this vulnerable group. Their work has highlighted
effective care coordination, continuity and transitions as key to improving health outcomes and
reducing healthcare costs. Available evidence suggests that two promising approaches to
improving continuity of care are to increase elders’ access to selected acute and palliative care
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services within the LTC sector, and to improve their “hand-offs” to and from acute care
hospitals. This paper makes the case that quality among elderly LTC recipients who also require
acute health care services may be enhanced by (1) avoiding preventable hospitalizations and (2)
improving their transitions to and from hospitals when these transfers are needed. Policy
recommendations and a research agenda to guide needed future changes in care for this
population are offered.
Transitions between LTC and Acute Care Hospitals Among Older Adults
Frail elders’ transitions between LTC and acute care hospitals are often triggered by
acute infections, adverse events such as falls, or exacerbations of chronic illnesses.[5] Patterns of
use of acute hospital services by elderly LTC recipients, particularly those residing at home or in
ALFs, have received limited attention. An early study conducted by Murtaugh and Litke[6]
revealed that about 20% of the five million elders responding to the 1994 National Long term
Care Survey received acute and post-acute services over a two year period with approximately
10% experiencing multiple hospitalizations. The few studies of acute hospital admissions
directly from NHs suggest considerably greater movement among this subgroup.[7-11] In these
studies, hospitalization rates between 56-83% within six months of admission to NHs were
reported with multiple readmissions common among 13% to 18% of these residents.[7, 8]
Problems Associated with Transitions in Care for this Population
There is evidence of serious problems related to the transfer of older adults to and from
acute care hospitals. Although some findings are based on studies of NH residents, the vast
majority of supporting data have been generated from studies involving chronically ill elders not
concurrently receiving LTC. This body of literature has identified four categories of overlapping
problems that detrimentally affect the health outcomes of this population and have negative
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economic consequences: poor communication; preventable declines in health status during
hospitalizations; inadequate discharge planning; and serious gaps in care during transfers to and
from hospitals.
Poor communication. Inadequate communication between and among hospitalized
elders, family members, and health care providers has been well documented.[12-15] The
involvement of multiple providers in hospitals, long-term care organizations and the community
(e.g., primary care provider) makes the coordination of information and decision making a major
challenge. The absence of integrated management information systems and patient databases
further hinders effective care transitions.[16, 17] Findings from a recent survey of 300 sequential
admissions of older adults to ten sub-acute or skilled nursing facilities (SNFs) from 25 hospitals
highlight problems related to the transfer of information.[16] Twenty-two percent of all transfers
had no formal discharge summary and more than half of the available summaries were illegible.
Unfortunately, health care providers, insurers and purchasers are reluctant to invest the resources
required to develop data systems to facilitate efficient transfers of information.
Negative effects of hospitalization. While hospitals are often the most appropriate site to
address acute care needs, an increasing body of evidence suggests that frail elders’ health and
safety may be compromised in these settings. For example, inadequate management of cognitive
impairment during elders’ hospitalizations frequently triggers a cascade of adverse clinical
events such as de-conditioning, falls, malnutrition and incontinence.[18-22] Consequently,
cognitive impairment among hospitalized elders has been independently associated with
increases in functional disability, lengths of hospital stay, hospital readmissions, and health care
costs.[23, 24]
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Inadequate discharge planning. Study findings reinforce that little attention is paid to
helping older adults and their caregivers understand the issues they will confront immediately
following hospital discharge.[25-28] Studies have consistently demonstrated that elders and their
caregivers do not know essential steps in managing the elder's condition.[26, 28-30] Family
members, in particular, have expressed high levels of frustration related to the absence of their
“voice” in the decision making process and their lack of preparation to meet elders’ care needs
following discharge.[4, 31, 32]
Gaps in Care During Transfers. As noted earlier, poor communication, inadequate
transfer of information and the absence of a single “point person” to assure continuity contribute
to gaps in care during critical transitions. These gaps are evident in problems commonly reported
during the immediate post-discharge period such as accessing essential supplies and services in a
timely manner, and managing symptoms, medications and other therapies.[26, 33] When questions
or concerns surface, elders and their caregivers are usually unable to contact acute care providers
for guidance.[26, 28-30]
As a result of these problems, the “hand-offs” of hospitalized older adults among multiple
providers and across settings have been linked to acute clinical events, serious unmet needs, and
poor satisfaction with care. Readmission rates among elders recently discharged from hospitals
are very high, with one-quarter to one-third considered preventable.[29, 30] While most of these
findings are derived from data of elders not concurrently receiving LTC services, there is no
evidence to suggest that their experience is different from those receiving LTC. Indeed, the latter
group may be at higher risk for negative outcomes because of overall poorer health status
complicated by increased frailty and higher rates of cognitive impairment. Studies are needed to
understand the impact of transitions in care among frail elders.
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Barriers to Addressing Transitional Care Problems
Clinical and non-clinical factors combine to pose significant barriers to addressing the
problems associated with transitions between the LTC sector and acute care hospitals. Prominent
among clinical barriers are: lack of providers’ knowledge, skills and resources; limited use of
palliative care; and a lack of quality performance measures. Regulatory and financial issues as
well as pressures from family caregivers and health care administrators are among the major
non-clinical barriers. A brief description of the nature and effects of each of these factors
follows.
Provider Deficits. A poorly understood barrier to effective care of frail elders is that
acute care providers often lack the knowledge, skills and resources needed to address LTC needs
during elders’ hospital stays.[2] Findings from focus groups involving teams of acute providers
highlight these issues.[34] For example, hospital providers reported that they often do not have
the skills or time to implement feeding, toileting or mobility strategies to ensure that elders are
adequately nourished or their functional abilities are maintained. Hospital staff’s challenges are
compounded by the lack of information from LTC staff regarding successful strategies to meet
elders’ unique needs. As a result, the nutritional and functional status among hospitalized frail
elders is often compromised, contributing to poor and costly outcomes.[34]
LTC providers face similar challenges in caring for elders prior to and following hospital
discharge. Data suggest that a high proportion of transfers to acute care settings may not be
necessary.[13],[35] Clinical experts in one study reported that about 40% of transfers of NH
residents to either the emergency department or hospital were avoidable because these elders had
health problems that could be safely cared for in the NH.[35] Reimbursement of most LTC
organizations has limited the availability of registered nurses and other highly skilled
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professionals. Currently, certified nursing assistants or home health aides are the primary
provider of most LTC services.[2] These paraprofessionals generally lack the knowledge and
skills needed to early identify and intervene on behalf of elders experiencing acute care
problems.[2] High turnover rates and inadequate investment in staff’s continued education
compound the problem.[2] Similar issues affect the quality of elders’ care during the immediate
post-discharge period.
Limited Use of Palliative Care. The unique barriers to the use of palliative care within
the LTC sector are noteworthy. Many elderly LTC recipients have debilitating, life-limiting
conditions for which on-site palliative care would be more appropriate than transfers to acute
care hospitals. Pain and uncontrolled symptoms affect between 25% and 50% of elders living in
the community and as many as 45% to 80% of NH residents.[36] Consequences include
depression, decreased function and socialization, poor quality of life and increased health care
utilization and costs.[36] The major foci of palliative care are effective management of pain and
other distressing symptoms and enhanced continuity of care.[12, 13]
Typically, paraprofessionals are not adequately prepared to identify and manage pain and
other symptoms in this population.[37] Elderly LTC recipients often have limited contact with
physicians or nurse practitioners, making effective palliation challenging. Additionally, nurses
and physicians are reluctant to use scheduled analgesics for chronic pain, particularly in NHs,
because of state and federal regulatory scrutiny related to the use of medications.[37]
Multiple factors reinforce the use of medical solutions and thwart the implementation of
palliative care models, even at elders’ end-of-life. Up to 40% of elders receiving LTC are
transferred to the hospital in the 30 days prior to their deaths.[14, 15] Each year, 500,000 NH
residents in the U.S. die in need of palliative care or with palliation delayed until the last few
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days of life.[14, 15] Lack of advanced care planning, difficulty recognizing terminal status of noncancer diagnoses, poor communication regarding elders’ wishes, legal liability concerns, and, a
narrowly defined Medicare Hospice benefit also hinder access to appropriate end-of-life care for
these elders.[12-15, 38]
Lack of Quality Performance Measures. The dearth of measures that capture effective
care coordination, continuity and transitions is one of the more significant barriers to improving
quality for this population. The selection of sensitive process and outcome indicators to promote
effective care in these areas is a major challenge. There is limited understanding of the natural
history of changes in health and quality of life among elders receiving LTC and on the
contributions of both individual and organizational characteristics to these trajectories. The
relationships between changes in health related quality of life, identified by leading scholars as a
focal point for elders receiving LTC, to other indicators of quality such as acute hospitalization
rates also are poorly understood.[1, 39-41] These data are essential to inform measure development.
The National Institute of Aging has recently funded a longitudinal study to begin to address these
knowledge gaps.[42]
The identification of providers accountable for transitions in care across hospitals and
LTC organizations also hinders quality measurement. Currently, mechanisms to ensure
accountability have followed the same pattern as health care reimbursement and financing. The
majority of existing standards reinforce healthcare delivery “silos” by focusing on processes and
outcomes within rather than across settings. Few focus on the actual experiences of frail elders
and family caregivers during transfers. Clearly, both acute and LTC providers are responsible for
the care and outcomes of these elders but identifying measures that capture their shared
accountability is challenging.
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There is some evidence that federal quality assurance programs and accrediting bodies
have begun to focus on the measurement of care transitions among elders.[3, 43-49] For example,
the National Quality Forum (NQF) recently endorsed the Care Transition Measure (CTM-3),
developed to assess the quality of care transitions from hospital to home from the perspective of
patients or their proxies.[44, 50] Continued investment in the design and testing of robust measures
of effective care coordination, continuity and transitions and facilitating their integration into
national performance measurement sets must be a priority for this population.
Regulatory Challenges. There are substantial regulatory barriers to assuring effective
care coordination and transitions among acutely ill elders, not receiving LTC. Medicare
regulations, for example, promote the delivery, monitoring and payment of acute care services
within separate and distinct silos including hospitals, home health care agencies or SNFs. As
noted earlier, gaps in care are common in a system that pays little attention to the continuing care
needs of elders moving across these silos. Discontinuities are compounded when elders are also
receiving LTC services. Within and across the acute and LTC sectors, different eligibility rules,
quality monitoring systems, criteria for reimbursement and funding streams create confusion and
sometimes conflicts for providers and, without question, add to the burden of family caregivers,
providers and administrators. Collectively, these structural barriers make the design and
implementation of rational, streamlined packages of services to meet elders’ needs very difficult.
Financial Challenges. There are multiple dimensions to the financial challenges
associated with effective care of LTC recipients who also need acute care services. Currently,
financial incentives encourage the use of hospitals to address frail elders’ acute care needs.
Acutely ill, frail elders fill empty hospital beds and also generate revenues for acute care
providers. Some LTC organizations, notably NHs, benefit from increased reimbursement for the
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post-care of elders in their skilled nursing units. While hospitals may not be the best site of care
to treat commonly occurring acute infections or acute episodes of chronic conditions, there are
few incentives for LTC organizations to offer such services. In addition to regulatory barriers,
these organizations are inadequately reimbursed to support the level and quality of staffing
essential to meet the needs of these acutely ill, frail elders. While few challenge the need for
improved care coordination for frail elders transferring to and from hospitals, nurses, physicians
and other providers are not reimbursed by for such services in the fee-for-service system. The
lack of financial incentives for care coordination for this population is especially problematic
given the aforementioned challenges to achieving coherent plans of care.
Recent national attention on improved care coordination and pay for performance (PFP)
promises to place a spotlight on existing financial barriers to improving healthcare quality and
decreasing costs for chronically ill elders. The Centers for Medicare and Medicaid Services’
(CMS) care coordination initiatives and demonstration projects evaluating PFP measures (e.g.,
tying Medicare hospital payments to quality of care measures) are examples of such efforts.[51]
Bridges to Excellence, a multi-state, multiple employer initiative, encourages advances in quality
across the healthcare system through measurement, reporting and financial rewards.[52] The
recently passed health coverage bill in Massachusetts outlines a PFP system in which healthcare
providers must meet certain quality standards in order to receive additional Medicaid dollars.[53]
As care coordination models and PFP programs develop and mature, several key features
emerge as focal points. First, collaboration among all stakeholders across the system will be
essential for success. Second, government programs such as Medicare and Medicaid will likely
adopt and influence widespread use of proven approaches. Finally, findings from these efforts
will extend quality measurement and reporting across the system, facilitate the adoption of
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information technology to improve healthcare efficiency and promote the alignment of financial
incentives to achieve quality and value. To date, the unique issues faced by elderly LTC
recipients who require acute care services have not been a focal point of these demonstrations.
Pressures from Families and Healthcare Administrators. Even when LTC staff members
are prepared to address the acute care needs of elders, pressures from family members who want
their loved ones to receive the “best” care may contribute to unnecessary transfers to acute care
hospitals.[34] Similarly, LTC administrators, concerned about malpractice actions, may pressure
staff to transfer elders to acute hospitals.[34] Lack of advanced care planning to clearly identify
elders’ wishes, poor communication with families before and legal liability issues are substantive
barriers to avoiding preventable hospitalizations.[34] Once hospitalized, acute care staff also may
be pressured by hospital administrators to discharge these elders as quickly as possible to
maximize reimbursement.
Search for Solutions to Address Barriers to Care Coordination, Continuity and Transitions
There are few studies of interventions designed to address the problems and barriers to
effective care transitions among acutely ill, frail elders, especially among those residing at home
or in ALFs. However, analyses of findings from the following related lines of inquiry suggest
areas for quality improvement: efforts to fully integrate acute and LTC; transitional care
innovations targeting chronically ill elders not concurrently receiving LTC; and innovative care
models focused on NH residents. Results from these efforts place a spotlight on the potential
benefits associated with avoiding preventable acute care hospitalizations and improving
transitions between LTC and acute care hospitals.
Avoiding Preventable Acute Care Hospitalizations. A number of government and
provider-led initiatives have attempted to strengthen the connections between the LTC and acute
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care sectors to better address the needs of frail elders. Analyses of findings from evaluations of
federal programs such as the Program of All-Inclusive Care for Elders (PACE) and Social Health
Maintenance Organizations [SHMOs],[2],[54-56] state efforts such as the Minnesota Senior Health
Option and Wisconsin Partnership,[41, 57, 58] and provider initiatives such as those spearheaded by
the National Chronic Care Consortium have informed our understanding of the unique
challenges confronting frail elders and receiving care from the LTC and acute care sectors and
highlighted the potential benefits of avoiding preventable acute care hospitalizations for this
population.[59-63] Early identification of elders’ acute care needs and increased access to selected,
evidence-based management of common conditions and palliative care services are prominent
among the key strategies suggested by available data. Results from studies of the following care
models designed to avoid preventable hospitalizations for NH residents or chronically ill elders
not simultaneously receiving LTC reinforce the potential value of this strategy but also raise
issues that warrant additional study.
Evercare Model. Findings from studies of the Evercare Model reveal the impact of more
intensive primary care provided to NH residents by certified nurse practitioners (NPs) in
preventing avoidable transitions.[57, 58, 64] This program enrolls NH residents in a risk-based
HMO, with nursing home costs covered by Medicaid or private insurance.[2] Evercare pays for all
medical services incurred by residents, regardless of the site where they are delivered. Thus,
there is no incentive for NHs to shift costs by hospitalizing residents. In one study of this Model,
over 1,470 NH residents receiving NP services in five sites were compared with two sets of
controls, a group of 831 residents in the same sites who did not enroll in Evercare and a group of
1,350 residents in NHs that did not participate in Evercare.[41, 58] In general, the active use of NPs
was positively viewed by family members. The incidence of hospitalizations was twice as high
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among controls compared to Evercare residents. This difference corresponded to Evercare’s use
of intensive service days within NHs.[64] On average, using an NP resulted in an estimated annual
savings in hospital costs of $103,000 per NP, suggesting the value of this approach in allowing
cases to be managed more cost-effectively.[64] Kane and colleagues suggest that more effective
use of these NPs is possible. In this study, the NPs major role was to guide NH staff to more
effectively care for residents.[58] Increased direct clinical involvement by NPs in the care of
elders at high risk for hospitalizations may be associated with additional improvements in
outcomes for this group but this hypothesis needs to be tested.
Hospital at Home. A recent report of a “hospital at home” program demonstrated the
clinical feasibility and efficacy of providing acute care in an elder’s home.[65] This prospective,
quasi-experimental study enrolled 455 community-dwelling older adults not currently receiving
LTC who would, in the absence of such a program, be hospitalized for an acute exacerbation of
pneumonia, heart failure, chronic obstructive pulmonary disease or cellulitis. At two of three
study sites, approximately 70% of those offered the option chose “hospital at home” over
traditional hospital care. At the third site, only 30% chose this option. The investigators
hypothesize that the launch of a new disease management program, the effects of a local nursing
shortage and other organizational factors affected the enrollment rate at this latter site. Enrolled
patients were identified in the emergency department, discharged to home where they received a
combination of nursing, physician and other services guided by a prescribed protocol. Compared
to acute hospital care, this innovation achieved similar quality standards and resulted in shorter
lengths of stay and reduced overall costs.[65] A higher proportion of elders were satisfied with
treatment in the “hospital at home” program with statistically significant differences reported in
the following four of nine domains assessed: satisfaction with their physician, comfort and
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convenience of care, admission processes and the overall care experience.[66] The applicability of
this approach to meeting the complex needs of acutely ill, community-based elderly LTC
recipients needs to be examined.
The Day Hospital. Modeled after the program offered within the British health care
system, the day hospital is based in a community setting. The Collaborative Assessment and
Rehabilitation for Elders (CARE) program at the University of Pennsylvania was an example of
such an initiative.[67],[68] The CARE program operated as a Medicare-certified comprehensive
outpatient rehabilitation facility (CORF).[69] This geriatric nurse practitioner (GNP) directed
interdisciplinary program targeted frail elders at high risk for hospitalization and other poor
outcomes. Older adults in this program had access to a range of health and rehabilitation services
for a few days each week up through a nine week period.[69] A quasi-experimental study revealed
improved function and decreased hospital use among the patients in the study group.[70] Notably,
there were no differences in outcomes between cognitively intact and impaired elders, suggesting
that this challenging latter group also benefited from rehabilitation services.[70] Changes in
reimbursement of CORFs resulted in the closing of this program.[69, 71, 72] Larger scale
evaluations of this model are needed.
Palliative Care in Nursing Homes. In 1996, the Palliative Care Program of the Medical
College of Wisconsin, in collaboration with Wisconsin’s Bureau of Quality Compliance and
Department of Health (regulatory agencies that monitor LTC in this state) launched a project
involving 87 LTC facilities designed to improve pain management practices.[37] Administrators
and directors of nursing at each site were required to sign letters of commitment. The
intervention included a series of four educational workshops spread over one year attended by
facility staff and administrators, and completion of a facility-specific action plan. Each facility
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was assessed at baseline and following completion of the intervention using 14 indicators of
effective pain management developed from national standards. At baseline, 14% of facilities had
met more than half of 14 indicators compared to 64 facilities post-intervention. The partnership
with state regulators helped to address facilities’ regulatory concerns. Key barriers identified
among the facilities that demonstrated little progress in this effort were staff turnover, lack of an
on-site champion and time. The key facilitator identified among successful organizations was
senior leadership commitment. Noteworthy is the fact many of these facilities have continued
their relationship with the faculty of the Palliative Care Program through quarterly meetings and
other palliative care projects.[37] This promising systems approach to improving and sustaining
“best practices” in palliative care is worthy of replication in other LTC organizations.
Improving Transitions Between LTC and Acute Care Hospitals. Transitional care
services optimally bridge the gap among a diverse range of providers, services and settings by
the systematic application of evidence-based interventions that promote the safe and timely
transfer of individuals.[73, 74] Influenced by an understanding of common problems during “handoffs” in care, these multidimensional interventions have typically incorporated strategies to
improve communication and transfer of information among elders, family caregivers, hospital
and primary care providers, enhance discharge follow-up and decrease gaps in care through the
use of a single, consistent provider. Among chronically ill elders transitioning from hospital to
homes, findings studies of predominantly nurse-led, interdisciplinary interventions have
consistently demonstrated improved quality and cost savings.[29-30, 75-77] The following are
examples of such approaches to care.
Care Transitions “Coaching” Intervention. A multidisciplinary team at the University of
Colorado Health Sciences Center has been testing an intervention designed to encourage patients
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and their family caregivers to assert a more active role during care transitions. In an earlier quasiexperimental study, patients and caregivers who received tools and support from a nurse
“transitions coach” were significantly less likely to experience rehospitalizations during the six
months following hospital discharge.[50] A more recent randomized clinical trial (RCT) of this
“coaching” intervention tested the impact of a set of tools (e.g., personal health record) to
promote cross-site communication and continuity across settings and guidance from an advanced
practice nurse (APN) among community-based older adults hospitalized with common health
problems in an integrated delivery system.[77] Study findings revealed that intervention patients
had lower all-cause rehospitalization rates through 90 days compared to controls. Mean hospital
costs were approximately $500 lower for intervention patients compared to controls at six
months.[77] Rigorous testing of this approach to care with the population of acutely ill elder
receiving LTC is needed.
APN Transitional Care Model. Since 1989, a multidisciplinary team based at the
University of Pennsylvania has been testing and refining an innovative model of care
coordination delivered by APNs for high risk older adults transitioning from hospitals to home.
The model incorporates state of the science interventions that focus initially on optimal
monitoring and managing elders’ symptoms and subsequently on preparing elders and their
family caregivers to better manage the elder’s care. In collaboration each elder’s physicians and
other health team members, a master’s prepared nurse assumes primary responsibility for
optimizing patient’s health during hospitalization and coordinating follow-up care. The same
nurse implements this plan for a defined period of time following discharge via home visits and
seven day per week telephone availability, substituting for traditional visiting nurse services.
Study findings from three RCTs have consistently demonstrated the capacity of this model of
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care to improve elders’ satisfaction, reduce rehospitalizations and decrease health care costs. The
most recently reported multi-site RCT tested a protocol directed by APNs designed to address
the health problems and risks common among elders throughout an acute episode of heart
failure.[30] When compared to the control group, members of the intervention group demonstrated
enhanced physical function, quality of life and satisfaction with care in the short-term and fewer
total rehospitalizations through 52-weeks post-discharge resulting in a mean savings of $5,000
per elder. [30] This approach to coordinating care for high risk, chronically ill elders needs to be
rigorously tested with elders receiving LTC who are transferred to and from acute care hospitals.
Collectively, results from these bodies of research suggest that the following are key
elements to improving care transitions: use of interdisciplinary teams guided by a single, highly
skilled nurse to communicate with elders, family caregivers and providers and coordinate care;
streamlined care delivery; information systems that span traditional settings; implementation of
evidence-based approaches; use of quality measures and other incentives to promote
accountability; and, availability of flexible funding and benefits.
Policy Solutions
Appreciation of the barriers to high quality care for acutely ill, elderly LTC recipients
coupled with evidence from evaluations of innovative care models suggest policy solutions to
improve health outcomes and reduce costs. The conceptual model described by Walter Leutz
offers a framework to present policy options.
Conceptualization. Recognizing the challenges imposed by the current context of care,
Leutz[54, 55] conceptualized potential strategies to integrate medical and social services for persons
with disabilities and chronic illnesses. He defined integration as the “search to connect the health
system with other human services in order to improve outcomes” (p. 78).[55] Leutz described
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three levels of possible integration: linkage, coordination and full integration. Linkage allows
individuals with mild to moderate needs to be appropriately cared for by existing systems by
improving transfer of information and communication between systems. Full integration applies
to the small subset of high risk, typically dually eligible, frail elders and requires pooling of
clinical and financial resources and the creation of new programs to meet their needs. PACE is
an example of full integration.
The level in the middle, coordination, focuses on individuals with progressively
increasing acute care and LTC needs. While operating primarily within existing sectors, this
level encourages the use of additional structures to address discontinuities and enhance
coordination of care delivery and benefits. Leutz’s concept of the level coordination appears
relevant to address the problems and overcome the barriers to effective transitions between acute
and LTC.
Key Assumptions. A number of assumptions underpin proposed policy solutions. The
first is that, for the foreseeable future, the financing and delivery of acute and LTC care in the
U.S. will continue to be a patchwork of public and private services and funding sources. The
second is that there is adequate evidence to justify a) increasing access to selected acute care as
well as palliative care services within LTC, and b) using nurse directed interdisciplinary teams,
guided by evidence-based care protocols, to facilitate transitions to and from hospitals for this
population.
Structures and Other Incentives to Enhance Coordination of Care Delivery. The design
and testing of robust quality indicators of care coordination, continuity and transitions from the
perspectives of frail elders, family caregivers and providers and integration of these indicators
into national performance measurement sets are essential to enhance the delivery of care
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coordination. The implementation of overarching monitoring systems that focus on the quality
of care elders receive across “silos” may help to mitigate structural barriers. The development
and use of clinical information systems that allow hospital, LTC and primary care providers to
access data related to elders’ health status and care needs and enable quality assessment and
improvement activities in the areas of care transitions also are essential. Information alone,
however, will be insufficient to address the care coordination challenges for this population.
Effective implementation of evidence-based strategies to prevent avoidable transfers and
improve cross-site care coordination will require new investments in the preparation of existing
and future health professionals. Increased support is needed for educational programs that
emphasize geriatrics, palliative care, interdisciplinary team care, advance care planning and care
coordination. Policy-makers should work with educators to disseminate “best practices” in
teaching each of these content areas to health professional schools, acute hospitals and LTC
organizations nationwide. Policies that encourage the recruitment, staff development and
retention of paraprofessionals also are needed. Particular attention should be paid to skill
development so these staff can better address the needs of elders confronting common acute
health problems or coping with chronic pain and other common symptoms.
Structures and Other Incentives to Improving Coordination of Benefits. Eliminating
regulatory barriers and creating financial incentives are prominent among the major policy
implications associated with increasing access to evidence-based approaches to care for this
population. Increased flexibility in funding with incentives to link funding streams and minimize
cost shifting could improve alignment of financial incentives with elders’ service needs.
Financial and other incentives are needed to support the level and quality of staff within LTC
organizations essential to manage common acute conditions and offer palliative care.
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Transitions of Elders Between Long-Term Care and Hospitals
Collaboration among relevant stakeholders such as state and federal regulatory bodies and
providers organizations in the design and implementation of these models should be encouraged.
Adequate reimbursement is necessary to support adoption of evidence-based transitional care
across settings and sectors. Finally, modification of the Medicare Hospice benefit to decrease
constraints on optimal use of available services by this population is recommended.
Conclusions
Available evidence suggests care of the rapidly growing population of frail elders in this
country requiring acute and LTC services could be enhanced by focusing on care coordination,
continuity and transitions. Two promising strategies to improving quality in these areas are to
avoid preventable acute care hospitalizations and improve the transitions between LTC and acute
hospitals when these transfers are needed. Health care leaders and policy makers need to
recognize both the challenges to optimizing quality and cost outcomes for this population and the
promise of evidence-based models of care. Unquestionably, investment in rigorous studies is
needed to understand the impact of transitions on frail elders, determine the most effective and
efficient models to enhance care coordination, continuity and transitions, and identify the
incentives to foster adoption of evidence-based models. While awaiting these findings, we are
fortunate that clinical and health services researchers have provided a blueprint for immediate
action. Their findings have informed policy changes aimed at addressing discontinuities in care
by creating structures and other incentives to improve coordination of care delivery and benefits
for this vulnerable population.
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