Date of Publication


Project Team

Jennifer Laurent, Jodie Archambault


Background: Transitions of Care (TOC) occur whenever an individual moves from one healthcare setting to another. Older adults are higher utilizers of healthcare services, including inpatient and emergent visits, than the general population (Tian, 2016), and thus experience more TOCs. Due to risk of poor outcomes at discharge from the hospital, rehospitalizations are a concern. Standardized TOC protocols have been shown to be beneficial in reducing rehospitalizations for this vulnerable population.

Purpose: Use current best practices to design and implement TOC for a rural community organization to reduce unintended rehospitalizations for older adults.

Methods: Best practices in TOC were assessed, formalized, and informed the intervention. Patients from three local hospitals were evaluated inpatient for TOC services. Registered nurses implemented TOC visits within 24 -72 hours post discharge, and completed a in-home care plan with need for additional followup. Clients were followed for 60 days following discharge for any unintended hospital events.

Results: 31 patients were referred for TOC. 21 were deemed appropriate referrals and 9 (42%) consented to the TOC visit. 2 patients (22%) of those who received TOC had an unintended hospital event within 60 days of discharge.

Conclusion: Implementation of TOC services post hospital discharge has a beneficial effect on reducing readmission and emergency visits for older adults in the short term

Document Type