Abstract
Older adults and their families experiencing, as well as clinicians facilitating, a care/setting transition can face difficult decisions often with limited information and under stressful circumstances. A multitude of factors converge to influence care transition outcomes—the individual’s circumstances, reimbursement incentives, business arrangements, workflow practices, information exchange, and clinical judgment. These decision points can have significant consequences for individuals and their families, particularly, when miscommunication or insufficient support occurs. This issue of Journal of Applied Gerontology focuses on care transitions among older adults from varying perspectives—environmental, societal, business, systems, clinical, and that of the individual—emphasizing the complex picture with many influences and suggesting opportunities to better support these critical junctures.
Fabius and Robison focus on individual, as well as societal and environmental, factors influencing living arrangement following a transition from a Medicaid nursing home stay facilitated by Connecticut’s Money Follows the Person (MFP) program. They find racial differences as well as transition challenges—specifically, financial, legal, and housing challenges—affect community living arrangements. Their findings stress the need for affordable, accessible housing options for older adults of any race seeking to live in the community rather than remain in an institutional setting.
Shield et al. highlight how system-level influences (Medicare reimbursement penalties for hospital readmissions, five star quality ratings for nursing homes, and bundled payments for select orthopedic procedures) combine to influence preferred provider relationships and skilled nursing facilities’ (SNFs’) willingness to accept more complex patients. They encourage policy and reimbursement changes to ensure that patients with dementia, eventual long-term care need, and multiple and complex comorbidities have equal access to high quality SNFs.
The next two articles indicate how available information influences and facilitates clinical decision making during care transitions. Kada measured the decisions of registered nurses and nurse assistants in Austria, with no clear optimal choice, to admit or not admit a hypothetical nursing home resident to the hospital while introducing quality of life (QoL) considerations and/or legal consequences. Eliciting considerations on residents’ QoL may marginally reduce transfers to a hospital. She also assessed the emotional burden for the nursing staff, finding that respondents who indicated they would admit the resident to the hospital that were made to weigh both QoL considerations and legal consequences had increased emotional strain. These two findings suggest that interventions to reduce avoidable hospital transfers among nursing home residents should focus on QoL, and clearer transfer guidelines could reduce nursing staff’s moral distress.
Meehan investigates the use of the “Continued Access” (CA) data sharing method that places a hospital-employed clinician as an onsite liaison at the long-term postacute care (LTPAC) facility to maintain access to the patients’ electronic health record (EMR) from three CA discharging hospitals relative to traditional discharge summary via fax and telephone follow-up for two hospitals not participating in CA at the LTPAC facility. LTPAC staff reported better transitions of care for CA hospitals discharges relative to non-CA patients as a result of more relevant, easy to access information, saving time, improving quality of care, and reducing 30-day readmission rates. Her findings emphasize the need for continued efforts to improve the quality and ease of use of information exchanged during care transitions and also the variability in processes that can result from differing business relationships.
The next two articles developed predictive models for nursing home entry and the likelihood of an adverse event following a hospital discharge. In the first article, the authors explore four models of multidimensional successful aging, defined as a combination of physical, psychological, and social dimensions, among Finnish oldest old (aged 90+ years) as a predictor of using long-term care (institutional care) for at least 90 days. Successful agers as a total group, and successfully aging women but not men, enter institutional care less than those who do not meet the criteria of “success.” The least restrictive criteria of successful aging, which did not require absence of disease or disability, distinguish those who manage, despite some difficulties, to remain independent and stay at their own home. This view of successful aging emphasizes autonomy, adaption, and resilience rather than an ideal state of being unattainable by the majority of the oldest old and should be encouraged both as a societal and clinical expectation.
The second predictive model article developed a short tool to estimate the likelihood that an older adult discharged from a hospital to home might experience an adverse event (AE; including Death, Institutionalization in assisted living or residential care, Readmission to a hospital, or Emergency department use [DIRE]) within 30 days. Based on only 10 items, it outperformed two other models and staff could use it to identify individuals in need of increased services to reduce subsequent transitions.
The final article tackles the important choice to use hospice as a final transition. The authors used an established behavioral theory to evaluate predictors of intentions to use hospice among White, higher income, highly educated older adults. They found the following associated with an intention to use hospice—greater hospice knowledge, a preference for QoL rather than aggressive treatments, normative beliefs supporting hospice, and participants’ higher overall confidence and perception of control that they could use hospice if they chose, if faced with a terminal illness. These results indicate areas of focus for educating older adults about hospice prior to a crisis to facilitate the opportunity to better care for individuals at the end of their lives.