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Engaging Older Adults in Their Transitional Care

Engaging Older Adults in Their Transitional Care

Seniors sitting together.

Dr. Susan Altfeld, clinical assistant professor of Community Health Sciences in the School of Public Health, organized a community-based forum for older adults in collaboration with the Illinois Transitional Care Consortium (ITCC).  The Consumer Voices Forum, which was funded by the University of Illinois Institute for Policy and Civic Engagement, took place at Plymouth Place Retirement Community in suburban La Grange Park.  It brought together several community-based organizations and Chicago institutions with the purpose of facilitating dialogue on relevant community issues facing older adults.  ITCC’s Chicago area community partners, Aging Care Connections and Solutions for Care, participated along with Rush University Medical Center’s Health and Aging Department and the Health and Medicine Policy Research Group.  

This community forum sought to engage older adults, their families and community stakeholders in a dialogue regarding transitional care. Over the past decade, the transition from hospital to home has been identified as a time of heightened risk, particularly for older adults.  A number of adverse events are associated with poor transitions, especially hospital readmissions, emergency department visits and nursing home placement.

For example,

  • Almost 1 in 4 Medicare patients are readmitted to the hospital within 30 days of discharge
  • 76% of 30 day readmissions are “highly preventable”
  • 40-50% of hospital readmissions are linked to social problems and lack of community resources

Care transition is a priority area in health care reform. Medicare has begun the funding of demonstration transitional care intervention projects and will be limiting payments to hospitals with high rates of rapid readmissions.  Several interventions have been developed by medical professionals, and more recently by social workers, to prevent the medication errors, compliance, and continuity of care problems that lead to these negative outcomes but these programs have neglected consideration of the perspectives of patients, families and others who work with and support older adults.

The purpose of the conference was to engage these constituencies in refining and improving The Bridge Model of transitional care ( The Bridge Model is the first and only social work based approach to transitional care.  It is evidence based and has shown an impact on

  • Readmissions
  • Physician follow-up
  • Understanding of discharge plan
  • Understanding of prescribed medications
  • Access and timeliness of community services
  • Mortality

Currently in operation at five hospital sites in Illinois, The Bridge Model coordinates post-discharge older adult care and integrates Aging Resource Centers inside hospitals. Bridge helps older adults to safely transition back to the community through intensive care coordination that starts in the hospital and continues after discharge to the community.

Dr. Altfeld and her co-facilitators engaged consumers in a discussion of unmet needs around transitional care.  Medication management emerged as an important area of concern.  Program participants said they were often confused by changing their medication regimens and ordering prescriptions from different providers.  They also voiced the need for physicians and other hospital staff to communicate more frequently with family members regarding their care.  Patients said that they were often too ill or fatigued to retain important information or ask questions during their hospitalization.  It appears that HIPAA regulations, designed to protect patient confidentiality, may not reflect the preferences of older adults and may contribute indirectly to post-discharge complications.  

Dr. Altfeld, who conducts research as an investigator within the Center for Research on Health and Aging of the Institute for Health Research and Policy, hopes to further explore these issues in future research and to test enhancements to The Bridge Model of transitional care intervention to better respond to these needs.  “There is very little research from the patients’ perspective,” Altfeld says.  “I’d like to change that.”

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