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Journal Article


Transitions of Elders Between Long-Term Care and Hospitals

The Issue

Elderly adults face an array of health challenges that often lead to multiple trips between their home or a nursing facility and the hospital. Frequent movements across settings of care are often linked to adverse events like medication errors, as well as unmet needs and dissatisfaction with care. In this Commonwealth Fund–supported article in Policy, Politics, and Nursing Practice, experts offer recommendations for improving care transitions and reducing preventable hospitalizations among the elderly to improve their health outcomes and quality of life.

What the Study Found

Some of the promising interventions include enhancing primary care services to older adults in nursing homes, training patients and their family caregivers to assert a more active role during transitions, and using advanced practice nurses to help monitor patients and prepare them and their families to be active participants in managing their care. Also needed, the authors say, are expanded dissemination and adoption of evidence-based care practices, new performance measures that can assess effectiveness of transitions, improved provider communication systems, aligned financial incentives, and the elimination of regulatory barriers in Medicare and Medicaid that obstruct care coordination and transitional care.


Bringing "state-of-the-science" innovations into health care delivery takes "dedicated leadership, expert problem solving, and innovative delivery models to systematically overcome the current status quo."

Publication Details



M. D. Naylor, E. T. Kurtzman, and M. V. Pauly, "Transitions of Elders Between Long-Term Care and Hospitals," Policy, Politics, and Nursing Practice, Aug. 2009 10(3):187–94.