Geriatric dispositions and transitions of care

Barbara Morano, Carmen Morano, Kevin Biese, Eric A. Coleman, Ula Hwang

Research output: Chapter in Book/Report/Conference proceedingChapterpeer-review


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.

Original languageEnglish
Title of host publicationGeriatric Emergencies
Subtitle of host publicationA Discussion-based Review
Number of pages13
ISBN (Electronic)9781118753262
ISBN (Print)9781118753347
StatePublished - 31 May 2016


  • Care transitions intervention
  • Emergency department
  • Geriatric patients
  • Nurse practitioner
  • Project BOOST
  • Project RED
  • Transitional care programs


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