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Transitions between care settings until death 

Transitions between care settings until death
Chapter:
Transitions between care settings until death
Author(s):

Elizabeth C. Gundersen

, Benjamin A. Bensadon

, and Joseph G. Ouslander

DOI:
10.1093/med/9780198701590.003.0039
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date: 18 October 2019

The problem of poor care transitions in geriatric patients is complex and challenging, and one which has become a priority across healthcare systems. Various interventions have shown success in improving transitions in care, but there is no one solution and more progress must yet be made, especially in the care of our most vulnerable patients, including those with dementia or at the end of life. Perhaps the most commonly recurring themes, however, are the need for multifaceted interventions and increased patient- and family-centred care. It is essential to discuss goals of care with patients and families, and then form treatment plans—including discharge plans—which respect those goals. Geriatric and palliative care clinicians are uniquely suited to contribute their skills in this area to improve care transitions.

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