Blog Harvey A. Friedman Center for Aging

Transition of care for older adults

Written by Behnaz Sarrami, MS, PharmD, TL1 predoctoral clinical research program alumnus

As we celebrate Older Americans Month, it is important to be reminded of those who struggle in an aging society with a health care system that is complex.

Imagine a 69-year-old woman admitted to the emergency room for the first time for a heart condition she didn’t know she had. She is surprised to learn that her heart is not working efficiently and hears the physician use the words “heart failure.” The nurse comes and gives her a “water pill” to reduce her current edema in her left leg. The next day, a pharmacist comes in and hands her six new prescriptions with instructions on how to use them.

The patient, who lives alone, goes home and tries to figure out how to use the new medications together with the five she was already taking. She could not pick up her medications at her local pharmacy and ask questions since she had no form of transportation. Therefore, she has her medications delivered to her home. She struggles to manage all her medications since she has early stages of dementia and Alzheimer’s. She starts feeling overwhelmed and depressed when she cannot remember what she was told and misses her doses. Her “transition of care” from the hospital back to her home was a struggle and two weeks later, she ends up back in the same hospital for exacerbation of heart failure with shortness of breath and swelling in both of her legs.

There are existing resources available within a hospital setting that can help older patients such as this example who live alone without support. A smoother transition of care can make a big difference for older adults being able to fully care for themselves at their own home instead of being placed at a nursing facility.

Hospitals could implement specialized training requirements for treating the complex medical needs of older adults, from the time they enter the hospital through discharge and follow-ups. Such requirements could include the addition of geriatricians as part of staff at every local hospital, or special screenings for dementia, fall risk, and in-home assessments while patients are still within hospital care.

At discharge, social workers could also help Medicare/Medicaid patients determine their eligibility for Medication Therapy Management (MTM) which is a free service offered as part of some Medicare plans. Additionally, pharmacists can be assigned to visit patients’ homes, do follow-up calls, answer questions, and help develop a medication routine specific to that patient’s lifestyle needs.

A physician’s referral to an occupational therapist is another resource available to patients. Occupational therapists are experts in suggesting home modifications and developing routines to help maximize independence. They can help find strategies to assist with self-care at home, in addition to reducing the risk of falls by observing daily activities such as bathing, dressing, cooking. They can even help with social events or leisure activities. Occupational therapists and pharmacists working together can make a significant difference in the quality of life of an older adult needing to balance a safe home environment and medication habits.

Ideally, a combination of all those possible scenarios could exist in a hospital. It would benefit both patients and healthcare providers to collaborate and implement a plan that works best for each hospital and their patient population. Transition of care is like a chain: we can either strongly connect the links, or leave it broken with some missing pieces.

For additional readings on this topic, check out:

  • Joint Commission Transitions of Care Portal
  • Joint Commission Hot Topics in Health Care | Transitions of Care: The Need for a More Effective Approach to Continuing Patient Care
  • Alzheimer’s Association Policy Brief | Reducing Potentially Preventable Hospitalizations for People Living with Alzheimer’s and Other Dementias

To learn more about the TL1 Predoctoral Clinical Research Program led by the Institute of Clinical and Translational Sciences, School of Medicine at Washington University in St. Louis, visit their website