Coordinating Care Across the Continuum

A Panel Discussion on Transitions in Care

On Wednesday, September 15th, Rush University Medical Center’s Older Adult Programs hosted Chicago Bridge’s panel discussion about transitional care. Older adults face unique challenges when moving across care settings. The increased prevalence of chronic conditions, functional and cognitive limitations, polypharmacy, social isolation, and other factors make older adults particularly vulnerable to poor transitions. The results can be which can be dangerous and costly for older adults, their families, and the national health care system as a whole as one in five Medicare beneficiaries return to the hospital within thirty days of discharge. Event panelists offered practical methods for addressing this critical issue.

The speakers represented transitional care from multiple different perspectives:

• Michele Packard, Enhanced Discharge Planning Program Social Worker at Rush University Medical Center, opened the forum with a presentation about her work as a clinician in a hospital-based telephonic short-term care coordination model utilizing master’s prepared social workers as transitional care managers.

• Caroline Ryan, Manager of the Aging Resource Center at Adventist LaGrange Memorial Hospital, described her unique program which integrates a community-based agency into a hospital to minimize delay in services and ensure linkage into appropriate community resources post-discharge.

• Claudia Cook, Eldercare Consultant at LivHOME, Inc., shared information about the role of private geriatric care managers in supporting older adults across transitions between care settings, such as from hospital to home, from hospital to skilled nursing facility, and from skilled nursing facility to home.

• Kristen Pavle, Policy Analyst with the Health and Medicine Policy Research Group, brought the audience up to date on current health care literature around transitions. She also educated the audience about efforts of the Illinois Transitional Care Consortium, a collaboration of community and hospital-based providers working to develop a transitional care model for the state of Illinois.

Presentations on each project were supplemented by a lively discussion with meeting attendees. All sixteen Bridge members present shared their professional and personal experiences with care transitions and swapped resources for supporting clients. The discussion also turned to the role of health care reform in bringing about change, particularly in relation to preparing for changes in Medicare reimbursement for readmissions within thirty days of a prior hospitalization.

Resources Available to Support Older Adults

Attendees were also encouraged to use resources available to support older adults across transitions, even if they do not work with a formal transitional care program. Such resources can be found online through organizations such as the National Transitions of Care Coalition, National Coalition on Care Coordination, and the United Hospital Fund’s Next Step in Care initiative. The Chicago Bridge is grateful for the opportunity to learn about this important topic from such passionate and knowledgeable colleagues.

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