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Geriatric Emergency Medicine Information Summary - Transitions of Care Michael LaMantia, MD, MPH Kristen Barrio, MD Kevin Biese, MD, MAT Definition & Fundamental Concepts “A set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same institution.” –American Geriatrics Society (2003) During transitions, patients are at risk for: • Medical errors • Service duplication • Inappropriate care • Critical elements of care plan “falling through the cracks” -American Geriatrics Society (2003) Conceptual model of effective transitional care (Coleman 2003): • Communication between sending and receiving clinicians • Preparation of the caregiver and patient for transition • Reconciliation of medication lists • Arranging a plan for follow-up of outstanding tests • Arranging an appointment with receiving physician • Discussing warning signs that might necessitate more emergent evaluation SAEM suggested Quality Measures to improve Transitional Care •

If nursing home patient goes to emergency department, then paperwork should state:  Reason for Transfer  Code Status  Medication Allergies  Contact Information for: o Nursing home o Primary care or on-call MD o Resident’s health care power of attorney or closest family member

If nursing home patient goes to emergency department, then paperwork should include:  Patient’s medication administration record

If nursing home patient goes to emergency room for requested studies, then:  Document the performance of requested tests or the reason why such tests were not performed


If nursing home patient goes to emergency department and will be released from the emergency department, then:  Emergency department provider should speak with the nursing home provider, primary care or on-call MD for the nursing home prior to discharge from the emergency department

If nursing home patient goes to emergency department and will be released from the emergency department, then written paperwork should state:  Emergency department diagnosis  Tests performed with results (and tests with pending results)

If nursing home patient goes to emergency department and is released back to the nursing home, then:  The patient should receive the recommended follow-up  The recommended changes to the patient’s medications or plan of care should be followed (or the reason why not followed documented)

References: Terrell et al. Quality Indicators for Geriatric Emergency Care. Academic Emergency Medicine 2009; 16:441-449.


Geriatric Emergency Medicine Information Summary - Transitions of Care