Creating a sustainable assessment tool and follow-up plan to improve care transitions for the frail elderly patient population: The TPRAS project

A variety of health care professionals effectively collaborating is often required to successfully coordinate care transitions of complex, frail older adult patients who are experiencing co-morbidities and cognitive decline. This paper describes an interprofessional approach using quality improvement methodology to iteratively develop and improve an acute geriatric medical unit's discharge planning and care transitions processes. The approach has shown early signs of positive outcomes at the patient, provider, and organizational levels. Health care leaders may use a similar approach in their efforts to improve patient, family and provider experiences and outcomes associated with discharge and care transitions planning for the older complex adult patient population.