A Call to Bridge Across Silos during Care Transitions.

摘要: Background Older adults with complex medical conditions are vulnerable during care transitions. Poor transitions can lead to poor patient outcomes and frequent readmissions the hospital. Factors Contributing Suboptimal Care Transitions Key factors related ineffective transitions, which suboptimal outcomes, include cross-site communication collaboration; lack of awareness wishes, abilities, goals care; incomplete medication reconciliation. Fundamental elements for effective put forth by The Joint Commission interdisciplinary coordination collaboration in shared accountability all clinicians involved provision appropriate support follow-up after discharge. Review Four Existing Models Consideration four existing models representing different health settings—Care Intervention® Guided Care, Interventions Reduce Acute Transfers (INTERACT®), Home Health Model Transitions—revealed that they important but limited their impact on across settings. Proposal Integrated Approach An innovative approach, (ICTA), is proposed incorporates best practices discussed this article identified as essential an transition while addressing limitations transitional models. ICTA's key characteristics seven unique stem from help achieve