Review of current conceptual models and frameworks to guide transitions of care in older adults

Older adults are at high risk for gaps in care as they move between health care providers and settings during the course of illness, such as following hospital discharge. These gaps in care may result in unnecessary re-hospitalization and even death. Nurses can assist older adults to achieve successful transitions of care by taking a systematic approach and individualizing care to meet patient and family health literacy, cognitive, and sensory needs. This article reviews trends in transitions of care, models, partnerships, and health literacy. Models described include the Transitional Care Model, Care Transitions Program, Project BOOST (Better Outcomes for Older adults through Safe Transitions), Project RED (Re-engineered Discharge), Chronic Care Model, and INTERACTII (Interventions to Reduce Acute Care Transfers). Approaches to transitions of care are discussed, and resources for geriatric nurses are provided.