Transitional Care

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Wenger NS, Young RT. Quality indicators for continuity and coordination of care in vulnerable elders. J Am Geriatr Soc. 2007;55 Suppl 2:S285-92.      

Coleman EA.Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex careneeds. J AmGeriatr Soc. 2003;51( 4):549-555

Coleman EA, Boult C, American Geriatrics SocietyHealth Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. JAm Geriatr Soc. 2003;51( 4):556-557.

Hughes RG, Clancy CM. Improving the complex nature of care transitions. J Nurs Care Qual. 2007;22( 4):289-292.

Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. J Hosp Med. 2007;2( 5):314-323.

Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA. 2007;297( 8):831-841.

 Shepperd S, Parkes J, McClaren J, Phillips C. Discharge planning from hospital to home. Cochrane Database Syst Rev.2004;(1)( 1):CD000313.

 Worrall G, Knight J. Continuity of care for older patients in family practice: How important is it? Can Fam Physician. 2006;52:754-755.

Walker C, Hogstel MO, Curry LC. Hospital discharge of older adults. how nurses can ease the transition. Am J Nurs. 2007;107( 6):60-70; quiz 71.   

National Guideline Clearinghouse (NGC).Guideline summary: Discharge planning for the older adult. In: National Guideline Clearinghouse(NGC)[website]. Rockville(MD): [cited 2008 Jan08]. Available: http://www.guideline.gov

Hickman L, Newton P, Halcomb EJ, Chang E, Davidson P. Best practice interventions to improve the management of older people in acute care settings: A literature review. J Adv Nurs. 2007;60( 2):113-126.

Boyd CM, Boult C, Shadmi E, et al. Guided care for multimorbid older adults. Gerontologist. 2007;47( 5):697-704.

Clarfield AM, Bergman H, Kane R. Fragmentation of care for frail older people--an international problem. experience from three countries: Israel, Canada, and the United States. J Am Geriatr Soc. 2001;49( 12):1714-1721.

Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients--development of a discharge checklist for hospitalists. J Hosp Med. 2006;1( 6):354-360.

Hickman L, Newton P, Halcomb EJ, Chang E, Davidson P. Best practice interventions to improve the management of older people in acute care settings: A literature review. J Adv Nurs. 2007;60( 2):113-126.  

Merriman ML. Pre-hospital discharge planning: Empowering elderly patients through choice. Crit Care Nurs Q. 2008;31( 1):52-58.  

Mistiaen P, Poot E. Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. Cochrane Database Syst Rev. 2006;(4)( 4):CD004510.

Naylor MD. A decade of transitional care research with vulnerable elders. J Cardiovasc Nurs. 2000;14( 3):1-14; quiz 88-9.

Smith SM, Allwright S, O'Dowd T. Effectiveness of shared care across the interface between primary and specialty care in chronic disease management. Cochrane Database Syst Rev. 2007;(3)( 3):CD004910.

Walker C, Hogstel MO, Curry LC. Hospital discharge of older adults. how nurses can ease the transition. Am J Nurs. 2007;107( 6):60-70; quiz 71.        

Wright K, Hazelett S, Jarjoura D, Allen K. The AD-LIFE trial: working to integrate medical and psychosocial care management models. Home Healthc Nurse. 2007;25(5):308-14. Review.

Gravolin M, Rowell K, de Groot J. Interventions to support the decision-making process for older people facing the possibility of long-term residential care. Cochrane Database Syst Rev. 2007;(3)( 3):CD005213.       

McCloskey R, van den Hoonaard D. Nursing home residents in emergency departments: A foucauldian analysis. J Adv Nurs. 2007;59( 2):186-194.

Parsons P, Boling PA. Patterns of emergency care use in residential care settings: Opportunities to improve quality of transitional care in the elderly. Home Health Care Serv Q. 2007;26( 4):79-92.

van Servellen G, Fongwa M, Mockus D'Errico E. Continuity of care and quality care outcomes for people experiencing chronic conditions: A literature review. Nurs Health Sci. 2006;8( 3):185-195.

• Transitional Care in the Elderly

Carr DD. Case managers optimize patient safety by facilitating effective care transitions. Case Manag. 2007;12( 2):70-80; quiz 81-2.

Crotty M, Rowett D, Spurling L, Giles LC, Phillips PA. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? results of a randomized, controlled trial. Am J Geriatr Pharmacother. 2004;2( 4):257-264.  

Levenson SA, Saffel DA. The consultant pharmacist and the physician in the nursing home: Roles, relationships, and a recipe for success. J Am Med Dir Assoc. 2007;8( 1):55-64.

Mion L, Odegard PS, Resnick B, Segal-Galan F, Geriatrics Interdisciplinary Advisory Group, American Geriatrics Society. Interdisciplinary care for older adults with complex needs: American Geriatrics Society position statement. J Am Geriatr Soc. 2006;54( 5):849-852.  

Watters CL, Moran WP. Hip fractures--a joint effort. Orthop Nurs. 2006;25( 3):157-65; quiz 166-7.