Care Transitions Intervention and Other Non-nursing Home Transitions Models

A transition from one care site to another is a vulnerable time for all patients, especially for frail older adults. While the care transition from hospital to home or postacute care facility has garnered the most attention, the American Geriatrics Society (AGS) defines transitional care as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location” [1]. Thus, a comprehensive view of care transitions includes any site of care spanning hospital, outpatient clinic, home, skilled nursing facility, or any other type of domiciliary setting in which a patient receives care.