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ERIC Number: EJ987390
Record Type: Journal
Publication Date: 2008
Pages: 9
Abstractor: ERIC
Reference Count: 41
ISSN: ISSN-1043-7797
Transitional Care
Naylor, Mary; Keating, Stacen A.
Journal of Social Work Education, v44 suppl 3 p65-73 Fall 2008
Transitional care encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of health care and across care settings. High-quality transitional care is especially important for older adults with multiple chronic conditions and complex therapeutic regimens, as well as for their family caregivers. These patients typically receive care from many providers and move frequently within health care settings. A growing body of evidence suggests that they are particularly vulnerable to breakdowns in care and thus have the greatest need for transitional care services. Poor "handoff" of these older adults and their family caregivers from hospital to home has been linked to adverse events, low satisfaction with care, and high rehospitalization rates. To understand the state of the science related to transitional care models for older adults in the United States and the roles of family caregivers in these models, the authors searched the Medline, CINAHL, and Social Work Abstracts databases using combinations of the following terms: (1) research; (2) ages 65 years or older; (3) continuity of patient care; (4) patient transfer; (5) discharge planning and postdischarge follow-up; and (6) transitional care. The search period was from 1996 to 2007. The search identified three promising approaches to improving the quality of care for chronically ill older adults: (1) increasing older adults' access to proven community-based transitional care services; (2) improving transitions within acute hospital settings; and (3) improving patient handoffs to and from acute care hospitals. In general, these approaches have focused explicitly on the patient and only implicitly target family caregivers. This article describes two models for each of the three categories.
Council on Social Work Education. 1725 Duke Street Suite 500, Alexandria, VA 22314. Tel: 703-683-8080; Fax: 703-683-8099; e-mail:; Web site:
Publication Type: Journal Articles; Reports - Descriptive
Education Level: Adult Education
Audience: N/A
Language: English
Sponsor: N/A
Authoring Institution: N/A
Identifiers - Location: United States