Care transitions by older adults from nursing homes to hospitals: implications for long-term care practice, geriatrics education, and research.

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.