The older person in transition: Implications for pathways of transitions of care

Older adults face many care transitions and often have diffi culty navigating a complex, fragmented health care system. Health care providers, older adults, and their caregivers face challenges in communicating effectively during care transitions. Suboptimal care during transitions can lead to poor patient satisfaction, clinical deterioration, and unplanned use of health services such as return to the acute care setting shortly after discharge from the hospital. This chapter highlights characteristics older adults bring to the health care experience, with special attention given to those characteristics that make them more vulnerable to transitions of care problems in contrast to other age groups. This chapter also discusses issues that lead to care fragmentation and increased numbers of care transitions among older adults. Lastly, this chapter makes recommendations to address and reduce the fragmentation in care delivery for older adults. Ultimately, the implications for pathways of transitions of care are addressed in this chapter.