Transitional care: looking for the right shoes to fit older adult patients.

Potentially avoidable hospitalizations are associated with high costs and an increased risk for iatrogenic conditions in older adult patients. Although care managers may be aware of the common potential pitfalls that may arise in the transfer of patients to and from the hospital defining best practice models has been difficult. Many current models of geriatric care have had little or no impact on lowering the rates of hospitalizations and rehospitalizations when formally studied. Health care reform legislation mandates initiatives involving new models of coordinated or guided care such as the medical home model and the accountable care organization. These new models too will face significant challenges in their attempt to provide the financial incentives and systematic changes needed to successfully address transitional care in older adults.