Geriatrics
Strategies to support continuity of care for older adults with frequent transitions between acute and long-term care.
Ensuring seamless continuity of care for older adults navigating repeated transfers between hospital settings and long-term care requires coordinated communication, person-centered planning, standardized processes, and proactive engagement from families, clinicians, and health systems.
July 21, 2025 - 3 min Read
As populations age, the journey of many older adults involves recurring moves between acute hospital wards and long-term care facilities. These transitions, while often medically necessary, introduce risks of fragmented care, medication errors, and unaddressed patient preferences. A foundational step is establishing a clear framework for information sharing that respects patient autonomy and protects privacy. Health systems can implement standardized transfer checklists, ensure timely availability of complete medical histories, and designate transition coordinators who liaise among hospital teams, nursing homes, and primary care practices. By aligning documentation and responsibilities, the right clinician becomes accountable for a patient’s care trajectory across every setting.
Families frequently bear the burden of interpreting complex medical instructions during abrupt changes in care location. Transparent, compassionate communication should be a core element of every transition. Providers must explain the rationale for a transfer in plain language, outline expected outcomes, and confirm patient goals, including advance care plans. This approach reduces confusion, supports shared decision-making, and helps families anticipate necessary supports after discharge. Training clinicians in empathic conversations and effective handoff storytelling—where the patient’s values inform decisions—can bridge cultural and linguistic gaps. In addition, accessible written summaries and multilingual resources empower caregivers to participate confidently in care planning.
Proactive planning, multidisciplinary teams, and patient-aligned goals guide transitions.
A successful continuity strategy begins with a robust information-sharing culture. Hospitals should maintain interoperable electronic health records that travel with the patient, carrying allergy lists, chronic disease histories, and current medications. When any transition occurs, a concise, evidence-based summary should accompany the patient, highlighting key risks and red flags to watch for in the next setting. Long-term care teams deserve timely access to these documents, and primary care physicians should be looped in early so medication reconciliation and preventive care can continue without delay. Regular audits of handoffs identify gaps, ensuring that data flows mirror the patient’s real-world journey.
Beyond data, continuity hinges on consistent care planning that anticipates common transition points. Multidisciplinary teams—including physicians, nurses, pharmacists, social workers, and rehabilitation therapists—should participate in bridging rounds where goals, milestones, and contingency plans are discussed. This collaborative approach helps align priorities across environments, reduces duplication of tests, and minimizes avoidable delays in therapy initiation. Regularly updated care plans reflect evolving cognitive and functional statuses, incorporating patient and family preferences, cultural considerations, and social determinants of health. When plans are shared, every provider knows when to escalate concerns and how to adjust supports rapidly.
Dedicated care navigators and proactive follow-ups sustain transitions.
Medication safety becomes particularly challenging during recurrent transitions. Polypharmacy increases the risk of adverse drug events when prescriptions are modified between settings. A pharmacist-led medication review before discharge can catch drug interactions, duplications, and dosing inconsistencies. Providers should emphasize clear administration schedules, verify pharmacy contact information, and arrange for timely medication delivery to avoid gaps. Deprescribing conversations are essential to reduce the burden of unnecessary drugs while preserving necessary therapies. Families benefit when they receive simple, written reminders about when to take medications and whom to contact if side effects occur during the first days after a transfer.
Care coordination programs that monitor patients between episodes of care reduce readmission rates and improve satisfaction. These initiatives assign a dedicated care navigator who travels with the patient through the care continuum. The navigator helps coordinate appointments, transport, and home supports, while also addressing social needs like nutrition, housing, and caregiver respite. By proactively coordinating post-discharge services, health teams can ensure continuity of rehabilitation services, home health visits, and follow-up bloodwork. A proactive touchpoint model—with brief check-ins during the first week after a transition—can detect problems early and prevent deterioration.
Patient preferences, education, and family engagement strengthen transitions.
Rehabilitation and functional goals often shift as patients move between acute and long-term care. Engaging physical and occupational therapists early in each episode ensures that mobility, feeding, and activities of daily living are preserved or improved across settings. Standardized assessment tools, such as frailty indices and cognitive screens, guide progress and reveal subtle declines that warrant intervention. Care teams should set realistic, measurable goals that reflect the patient’s daily routines and personal aspirations. When therapists document progress in compatible formats, information remains accessible to all team members, enabling timely adjustments to exercise plans, assistive devices, and environmental modifications.
Person-centered care plans should incorporate family insights, cultural beliefs, and patient preferences. Shared decision-making respects autonomy even when medical imperatives press for swift action. Practitioners can invite family members to participate in rounds, ask clarifying questions, and verify that the care plan aligns with the patient’s values. Educational conversations should cover what to expect during transitions, possible side effects, and red flags requiring urgent attention. By validating caregiver expertise and acknowledging their emotional experience, teams build trust and empower families to advocate effectively for the patient’s wishes.
Education, culture, and feedback loops underpin durable continuity.
Telecommunication tools offer practical support for monitoring patients as they move between facilities. Video check-ins with nurses or remote monitoring of vital signs can detect subtle changes early, enabling timely interventions without hospitalization. Digital platforms can house patient preferences, care plans, and contact information accessible to both hospital and care-home staff. However, technology must be user-friendly and secure, with contingency plans for those who lack digital literacy. Training programs equip clinicians to use these tools confidently, while privacy safeguards protect sensitive data. When used thoughtfully, technology enhances continuity without sacrificing the human connection that patients and families rely on.
Training and performance feedback create a culture of continuous improvement. Organizations should offer ongoing education about best practices in transitions, including culturally competent communication, medication reconciliation, and effective delegation. Regular simulation exercises, peer coaching, and after-action reviews reveal common pitfalls and effective remedies. Leaders can tie transition metrics to compensation or recognition to reinforce accountability. Sharing success stories from well-maintained transitions motivates teams to adopt proven strategies. Importantly, frontline staff voices must drive updates to transition protocols, ensuring that policies stay grounded in real-world experiences.
Measuring success in continuity of care requires meaningful metrics that reflect patient well-being rather than process checkboxes. Key indicators include time from hospital admission to completion of a transfer summary, rates of complete medication reconciliation, and patient-reported understanding of discharge instructions. Tracking 30- and 90-day readmission rates, functional status changes, and caregiver burden provides a broader view of impact. Data should be analyzed across settings to reveal where transitions fail and where they succeed. Transparent reporting to families and patients builds trust, while benchmarking against peer institutions identifies opportunities for shared learning and targeted improvement.
A sustainable strategy combines policy alignment, resource investment, and community partnerships. Payers and health systems can support continuity by funding transition coordinators, interoperable records, and home-based services that prevent unnecessary hospital stays. Community organizations can assist with transportation, nutrition, and social supports that stabilize a patient’s living situation during fragile periods. Clinicians should advocate for streamlined admission and discharge processes that reduce delays and duplicate entries. By prioritizing continuity at every level—from bedside care to policy design—older adults experience safer, more dignified journeys across the care continuum.
