Transitional Care Model

Description/Overview: A growing body of science suggests that older adults coping with multiple chronic conditions and complex therapies are particularly vulnerable to breakdowns in care. Insufficient communication among providers and across health care agencies, inadequate patient and caregiver education, poor continuity of care, and limited access to services are among the major factors contriubting to negative quality and cost outcomes. Despite consistent positive outcomes, research-based approaches to enhance transitions in care have not routinely been integrated into clinical practice. Given the projected growth of the population of older adults with complex care needs, there is a critical need to bridge the chasm between evidence-based practices and current approaches to such care. This presentation will describe the efforts of a multidiscplinary team based at the University of Pennsylvaniato advance the science related to transitional care as well as to translate research findings into the "real world" of clinical practice.