Care transitions programs for older adults—a worldwide need

In many countries around the world, including the United States, care for vulnerable older people is fragmented, especially at the time of hospital discharge and in the postacute hospital period. Thus, a major challenge for health care systems is to deliver the right type of post-acute care, in the right setting, by the right health care professionals, and for the right length of time. Care transition programs should avoid unnecessary harm related to poor transfer of care between settings, and address common problems as care transitions occur. In the US, Medicare, the major health insurance for older people, is incentivizing value-based over volume-based care, and financially penalizing hospitals for high 30-day readmission rates. In value-based care programs such as Medicare managed care, accountable care organizations, and bundled payments, effective care transitions programs are financially feasible because they have the potential for substantial cost savings from preventing unnecessary emergency department visits, hospital readmissions, other misuse of resources, and costly complications for patients and their families. In this special article, we provide a brief overview of the challenges of care transitions, and elements of care transitions programs developed and tested in the US that could be adapted to the dynamic, heterogeneous health care system in Europe as well as other countries around the world.