Transitions of care: what is the role that home care plays?

摘要

The impact of home care on transitional care is imperative to understand as our healthcare system undergoes scrutiny. We are all looking for ways to deliver more cost-effective care, particularly for the older population for whom care is most costly. When planning care for this population with multiple, complex health problems and geriatric syndromes, especially in combination with age-related changes, as well as psychological, social, and environmental changes, preventing fragmentation of care and breakdown in communication are serious challenges. Although Medicare (A), as an entitlement, provides basic healthcare (hospital, hospice, and home care) coverage for most adults age 65 and older, healthcare is extremely expensive, primarily due to breakdowns within the system and specifically in handling transitions. What are the basic factors within our healthcare system that contribute to patients "falling through the cracks"-especially for the more challenging, complex older patients?