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ABSTRACT
The advent of transitional care represents one part of a larger movement in health services delivery to improve quality of care and health outcomes and to reduce costs. Related efforts include the development of other chronic care coordination models and the movement toward integrated systems of care, both across institutions providing care and across different medical specialties. Transitional care arguably represents the most complex of care models, given that, by definition, it follows the care needs of individuals over time as they traverse multiple settings (institutional, home, and community-based) and are cared for by a diverse range and combination of health care professionals, paraprofessionals, and family caregivers.
In this chapter, we review what we have learned about the "state of the art" of transitional care for older adults. We identify the key components and stakeholders associated with transitional care and offer observations about how to integrate this information into our next steps for planning. To better conceptualize and advance such efforts, we introduce a Systems of Care (SOC) philosophy and a "7P" strategic planning framework that detail the components of transitional care and the strategic pathways and actions needed to ensure that its tenets are broadly adopted and disseminated. Although successful efforts to develop transitional care have been advanced in recent years, we still have a distance to travel before we can ensure that all older adults with complex chronic and acute health conditions will have access to quality transitional care.
INTRODUCTION
This book has provided a rich discussion of the different aspects of transitional care and a comprehensive portrait of the consumers for whom transitional care models have been developed. We have learned about their overall health status and level of functioning, and about how the full range of health needs and complex comorbidities they experience has implications for the delivery of effective transitional care. We have also learned about the active roles assumed by consumers and family members as they navigate through transitions of care, and about the practical, legal, and ethical decisions faced at every turn.
The chapters have illustrated the involvement of family caregivers as providers of direct care and gatherers and communicators of information - often acting as brokers between the consumer and the health care system. We...