11.1 Transitions of Care

ANCC GERO-BC Domain II skill II-B-4—care coordination—treats the older adult’s journey across settings as a nursing responsibility, not a clerical afterthought. Transitions of care are movements between locations or levels of care (acute hospital, emergency department, skilled nursing facility, inpatient rehab, assisted living, home health, hospice, primary care). For older adults, each handoff multiplies risk: incomplete medication lists, lost advance directives, unexplained cognitive change, and caregivers who never received teach-back.

On the exam, stems often describe a “routine discharge” that fails because nobody owned reconciliation, follow-up, or home safety. Your job is to identify the highest-leverage nursing action that closes the gap between settings.

Why Transitions Fail Older Adults

Aging physiology, polypharmacy, sensory/cognitive limits, and fragmented payment systems collide at discharge. Common failure modes include:

High-risk transition profiles deserve intensified coordination: recent delirium, ≥5 medications (especially anticoagulants, insulin, opioids, digoxin), heart failure or COPD exacerbation, new oxygen or wound care, live-alone status, limited English proficiency, low health literacy, prior 30-day readmission, and inadequate caregiver support.

Medication Reconciliation Across Handoffs

Medication reconciliation is the systematic comparison of medication lists at every transition—admission, transfer, and discharge—to resolve omissions, duplications, dosing errors, and unintended discontinuations. In gerontological practice:

1. Obtain the best possible medication history (brown-bag review, pharmacy fill data, caregiver interview, EHR). Do not trust a single source.
2. Compare to current orders and resolve discrepancies with the prescriber.
3. Produce a final discharge list that names drug, dose, route, frequency, indication, and stop dates for short courses.
4. Explain changes in plain language: “Continue,” “Stop,” “New,” “Changed dose.”
5. Confirm the person can obtain medications the same day (pharmacy hours, cost, delivery, prior authorization).

High-alert classes for older adults at transition: anticoagulants/antiplatelets, insulin and other hypoglycemics, opioids, benzodiazepines, digoxin, and diuretics. A missing “hold warfarin while INR high” instruction is a classic GERO-BC trap.

Structured Communication Tools

SBAR for clinician-to-clinician handoff

Situation, Background, Assessment, Recommendation keeps verbal and written handoffs focused. For older adults, embed geriatric essentials in Assessment/Recommendation: baseline cognition vs. current CAM status, fall risk, skin integrity, hearing/vision aids location, code status, and who holds decision authority.

IDEAL discharge planning elements

Many organizations adapt AHRQ IDEAL principles:

• Include the patient and family as full partners
• Discuss key items (meds, warning signs, appointments, home needs)
• Educate throughout the stay—not only at the door
• Assess understanding with teach-back
• Listen to concerns and negotiate realistic plans

Education done only at discharge, under time pressure, with hearing aids in a drawer, fails teach-back and fails the person.

Evidence-Based Transitional Care Models

GERO-BC expects recognition of model principles, not memorizing every protocol step.

Shared themes: early planning, medication mastery, scheduled follow-up, red-flag literacy, and continuity of a responsible clinician or coach.

Setting-Specific Transition Priorities

Hospital → home: Confirm durable medical equipment delivery, home health referral if skilled need exists, transportation to first appointment, meal access for the first 72 hours, and who will assist with ADLs overnight.

Hospital → SNF/rehab: Send complete med list, wound photos/orders, therapy goals, delirium history, isolation status, and goals-of-care. Receiving nurses need the why behind restrictions (e.g., soft diet after stroke).

SNF → home: Reassess whether the person can perform ADLs with available help; update the medication regimen after rehab changes; ensure primary care and specialists know the discharge date.

ED treat-and-release: Older adults sent home at night with new prescriptions and no caregiver are high-risk. Nurse coordination includes same-day pharmacy access, next-day primary care/home health contact, and clear return precautions.

Teach-Back and Red-Flag Scripts

Ask the person (or caregiver) to explain, in their own words:

• Which medicines changed and how they will take them tonight
• Three warning signs that require a call or ED visit
• When and where the follow-up appointment is
• Who to call for questions (name/number)

Example HF red flags: sudden weight gain (e.g., >2–3 lb overnight or provider-specified threshold), worsening dyspnea/orthopnea, new confusion, chest pain. Tailor flags to the diagnosis; avoid generic “call if you feel worse.”

Continuity Documents That Must Travel

Ensure the receiving setting has:

• Reconciled medication list and allergies
• Problem list and recent hospital course summary
• Baseline and current cognitive/functional status
• Advance directive / POLST / surrogate contacts
• Pending labs/tests and who owns follow-up of results
• Wound, device, and isolation instructions
• Preferred language and communication adaptations

Coordinating Timing and Accountability

Name a responsible party for each critical task: who schedules the cardiology visit, who picks up oxygen, who fills the pillbox on day one. Ambiguous “the family will handle it” is not a plan. When capacity or caregiver availability is uncertain, escalate to case management and delay unsafe discharge until a safer plan exists—advocacy is care coordination.

Exam Pattern to Expect

GERO-BC items typically ask which action best prevents readmission, which handoff element is missing, or which patient is highest priority for intensified transitional support. Prefer answers that complete reconciliation, verify understanding with teach-back, secure timely follow-up, and include caregivers over answers that only “provide a pamphlet” or “tell the patient to call if needed.”