Phase V .Apa seven
Influence of Transitional Care in Hospital Readmission among Elderly Patients.
Dania Morejon
Florida National University
May 27, 2021
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Influence of Transitional Care in Hospital Readmission among Elderly Patients.
Transitional care is offered to a patient when they are leaving one care setting such as a
hospital, nursing home or intensive care unit into another setting. Transitional care interventions
ensure the continuity of quality care to the patient and the coordination of healthcare between
different healthcare providers (Menezes et al., 2019). Successful transitions require trained
practitioners and health plans indicating the patient’s medications, previous treatment plans, and
healthcare preferences. Transitional care can occur within care settings such as from primary care
to intensive care, between settings such as from a nursing home to a hospital, between healthcare
providers such a specialist to a palliative care medical provider, or across different health
conditions. Transitional care is critical for older patients since they have unique needs compared to
other populations especially when transitioning from the hospital to nursing homes or individual
residences (Menezes et al., 2019). Lack of proper transitional care may lead to emergency hospital
readmissions and other medical unplanned events.
Multiple complicated conditions are barriers to managing healthcare needs among older
patients. Care transition is thereby important for this population to reduce the risk of infections and
readmission (Fønss et al., 2021). Nurses ensure the environment and the services provided are safe
for effective passage from one setting or specialist to the other. Older patients receive diverse
forms of care from different healthcare providers owing to multiple chronic conditions. They are in
the greatest need of successfully transitional care. Poor transitional care leads to unpleasant events,
dissatisfaction, and mistrust of the healthcare institution and medical providers, and a high
readmission rate.
Previous literature has identified various factors associated with ineffective transitional
care. Some of these include poor communication between medical providers, incomplete patient
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information, lack of awareness and education among older patients, and cultural and language
barriers (Fønss et al., 2021). These factors lead to gaps in the provision of quality healthcare
among older patients. Religious and cultural barriers can be especially challenging to nurses due to
a lack of cultural-based competency. Some religions such as Islam state that make members of the
family or heads of households should make decisions for every member of the family. Women are
not allowed to make decisions without consulting male members. Nurses find this challenging and
time-consuming when deciding on the specific transition care interventions since they have to
consult before every decision. There is also uncertainty in the decisions made since they may not
reflect the patient’s needs.
Healthcare needs for older adults are expected to increase because statistics indicate an
increase in the elderly population between 2016 and 2080. According to the U.S Census Bureau
(2020), the older population has increased since 2010 with a 3.2% increase from 2018 to 2019. The
increase has also led to ethnic and racial diversity in the population. This has led to the demand for
healthcare that is specific to individual needs. Changes in demographics will lead to challenges in
the provision of transitional care interventions. Older adults who require medical care are unable to
care for themselves due to limited physical and mental functions. Healthcare institutions, therefore,
need to provide primary and secondary healthcare.
Older adults with complex conditions are at a high risk of accidents which may lead to
readmission. Findings from the literature have indicated poor management of older patient’s needs
leads to consequences for the patient, healthcare institutions, and professionals. The consequence
to the patient includes reduced health status and poor healthcare experiences. However, the most
significant problem is avoidable readmission or rehospitalization. Research on hospital
readmission has indicated while most readmissions are necessary, rehospitalization of 20% of older
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persons with chronic conditions could be discovered earlier and prevented (Fønss et al., 2021).
Readmission of older adults has an impact on society especially the cost of caring for older patients
and meeting their unique needs. Medicare healthcare costs increase when a patient has more than
one chronic condition. In 2011, the cost of an older patient with one chronic condition was $2,097
while $31,453 was allocated to patients with four or five chronic conditions (Weeks et al., 2018).
High healthcare costs are attributed to older patient’s readmission due to poor transitional care.
Unforeseen readmission occurs due to a lack of proper planning during discharge,
medication errors, and lack of communication between medical providers in the hospital and the
older patient’s caregiver. Family caregivers have a major role in offering older patients with
support in the hospital and after they transfer to a different care setting (Allen et al., 2017).
However, they face enormous burdens since caregiving may weigh on their physical and emotional
states. Family caregivers are frequently left out of the design and planning phase of transitional
care interventions and are unaware of the values, requirements, and goals of care (Naylor et al.,
2017). Nurses must consider the role of family caregivers in transitional care and work closely
before the patient is discharged and during the actual transfer of the patient to a different setting.
Hospital readmission has devastating effects on older adults and is costly and dangerous.
Poor transitional care leads to readmission after less than 15 days of being discharged. Most
seniors are readmitted for pulmonary infections, pneumonia, and heart failure (Naylor et al., 2017).
Older patients acquire hospital-acquired infections from frequent readmission that worsens their
complications. Readmission has adverse consequences for hospital staff and medical providers too.
Older patients are likely to blame medical providers for readmission and the hospital for poor
quality healthcare. This discredits the healthcare institution leading to decreased number of patients
seeking care in the hospital.
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The problem of hospital readmission among seniors due to poor transitional care is
significant to nursing practice because nurses have a role in ensuring smooth transitions that reduce
rehospitalization. Nurses help in coordinating healthcare activities in different care settings and are
active agents in the transformation of healthcare delivery through the improvement of care
transition. Nursing care is dependent on the older patient’s medical needs. Patients with acute
conditions require post-acute care services for instance rehabilitation, outpatient, and home nursing
services (Menezes et al., 2019). Nurses must determine the appropriate post-care intervention for
every older patient for optimal outcomes. It is important to consider the patients’ medical needs,
physical and mental capacity, and the environment they are transitioning to. The interaction and
relationship formed between the nurse and the older patient are vital to improving transitional care.
During the provision of healthcare, nurses interact the most with older patients compared to
other medical providers. They learn the patient’s history and other information that they use to
design transitional plans. Through the information, they can identify barriers that may contribute to
readmission. Financial barriers are common in transitional care. Older patients and their families
are not able to meet medical needs such as medication for multiple chronic conditions, nursing
home expenses, food, and adult diapers for those who are physically challenged. Family members
and caregivers should communicate to the medical team if any barriers will impact a successful
transition. This allows proper planning and identification of the proper transitional setting.
The role of nurses is to ensure timely and efficient transition by sharing information with
caregivers and clinicians and coordinating with the medical team. The nurse needs to show the
patient and their caregiver how to use technology to communicate with medical providers in case
of a problem. They are also significant in follow-ups to assess the older adult’s health status to
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reduce hospitalization. Nursing is significant since the practice promotes successful transitions and
supports the healthcare needs of the patient which reduces readmission.
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References
Allen, J., Hutchinson, A. M., Brown, R., & Livingston, P. M. (2017). User experience and care for
older people transitioning from hospital to home: Patients’ and carers’ perspectives. Health
Expectations, 21(2), 518–527. https://doi.org/10.1111/hex.12646
Fønss Rasmussen, L., Grode, L. B., Lange, J., Barat, I., & Gregersen, M. (2021). Impact of
transitional care interventions on hospital readmissions in older medical patients: a
systematic review. BMJ Open, 11(1), e040057. https://doi.org/10.1136/bmjopen-2020-
040057
Menezes, T. M. D. O., Oliveira, A. L. B. D., Santos, L. B., Freitas, R. A. D., Pedreira, L. C., &
Veras, S. M. C. B. (2019). Hospital transition care for the elderly: an integrative review.
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Naylor, M. D., Shaid, E. C., Carpenter, D., Gass, B., Levine, C., Li, J., Williams, M. V. (2017).
Components of Comprehensive and Effective Transitional Care. Journal of the American
Geriatrics Society, 65(6), 1119–1125. https://doi.org/10.1111/jgs.14782
US Census Bureau. (2020, June 25). 65 and Older Population Grows Rapidly as Baby Boomers
Age. Retrieved May 27, 2021, from
https://www.census.gov/newsroom/press-releases/2020/65-older-population-grows.html
Weeks, L. E., Macdonald, M., Martin-Misener, R., Helwig, M., Bishop, A., Iduye, D. F., &
Moody, E. (2018). The impact of transitional care programs on health services utilization in
community-dwelling older adults: a systematic review. JBI database of systematic reviews
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