Older adults residing in nursing homes are among the most vulnerable members of our
society. A large percentage of nursing home residents are at risk of experiencing
a care transition to a hospital. This review examines care transitions from nursing
homes to hospitals, focusing on resident safely, effectiveness and timeliness of these
transitions, and ways to enhance resident-centered care. Recommendations to improve
care include promoting clear communication, managing medications, encouraging appropriate
use of formal advance directives, providing timely access to care to reduce the risk
of potentially avoidable hospitalization, and promoting an interdisciplinary resident-centered
approach in geriatrics education. Studies examining nursing homes that have adopted
models of care that emphasize resident autonomy as well as qualitative research focusing
on in-depth ethnographic approaches can provide new perspectives of care transition
experiences, and help to identify additional ways to improve care.
Keywords
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Published online: March 25, 2010
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© 2010 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.
