Geriatric dispositions and transitions of care

This chapter presents a case of 67-year-old woman who had increasing number of emergency department (ED) visits for shortness of breath. There are a number of evidence-based transitional care programs designated to reduce hospital readmissions such as the Care Transitions Intervention, Project RED, and Project BOOST. When developing a specific transitional care model, the following elements must be considered: early engagement and assessment; in-person or telephonic follow-up; schedule of follow-up; duration of intervention; staffing; and outcomes desired. Whether utilizing a nurse, nurse practitioner (NP), or social worker-driven model of transitional care, there is a consensus on how to improve outcomes as patients transition between settings of care. The elements necessary in ED to home transitional care are those of a transitional care initiative currently being implemented and launched as part of an innovative model of care with Geriatric Emergency Department Innovations in care through workforce, informatics, and structural enhancements.