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J Gerontol Nurs. 2012 Nov;38(11):40-7. doi: 10.3928/00989134-20121003-04. Epub 2012 Oct 15.

Transitions in care among older adults receiving long-term services and supports.

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Duke University School of Nursing, durham, NC, USA.


Recipients of long-term services and supports (LTSS) frequently transition between LTSS settings (e.g., assisted living facilities, nursing homes) and hospitals for acute changes in health. In this qualitative study, we analyzed findings from interviews with 57 recently hospitalized LTSS recipients and their family caregivers and described barriers and facilitators to high-quality care to support older adults through these care transitions. The themes that emerged strongly suggest that LTSS recipients and family caregivers do not receive needed information about the reasons for their transfers to hospitals, medical diagnoses, and planned treatments to address acute changes in health. Our findings indicate an urgent need for nurses and other health care team members to talk with LTSS recipients (and family caregivers) and ensure they are engaged and informed participants in care. We also found the need for research to test evidence-based transitional care for high-risk LTSS recipients and their family caregivers.

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