Regardless of age: Incorporating principles from geriatric medicine to improve care transitions for patients with complex needs

Alicia I. Arbaje, Devan L. Kansagara, Amanda H. Salanitro, Honora L. Englander, Sunil Kripalani, Stephen F. Jencks, Lee A. Lindquist

Research output: Contribution to journalArticle

27 Scopus citations


With its focus on holistic approaches to patient care, caregiver support, and delivery system redesign, geriatrics has advanced our understanding of optimal care during transitions. This article provides a framework for incorporating geriatrics principles into care transition activities by discussing the following elements: (1) identifying factors that make transitions more complex, (2) engaging care "receivers" and tailoring home care to meet patient needs, (3) building "recovery plans" into transitional care, (4) predicting and avoiding preventable readmissions, and (5) adopting a palliative approach, when appropriate, that optimizes patient and family goals of care. The article concludes with a discussion of practical aspects of designing, implementing, and evaluating care transitions programs for those with complex care needs, as well as implications for public policy.

Original languageEnglish (US)
Pages (from-to)932-939
Number of pages8
JournalJournal of general internal medicine
Issue number6
StatePublished - Jun 2014



  • care transitions
  • geriatrics
  • healthcare delivery
  • utilization
  • vulnerable populations

ASJC Scopus subject areas

  • Internal Medicine

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