Improving Transitions of Care Through Effective Family Caregiver Partnership: A Collaborative to Benefit Frail Elders

When older adults move from one care setting to another, such as from hospitals to nursing homes, or nursing homes to home care, the information that is shared with them and their caregivers is often confusing, contradictory, or missing critical parts, which can lead to serious consequences.

In 2009, we expanded our Improving Transitions of Care program with a Collaborative project, Improving Transitions of Care Through Effective Family Caregiver Partnership, awarding grants to 14 project teams from nine different counties to integrate the use of the Care Transitions Intervention with the “Next Step in Care: Family Caregivers and Health Care Professional Working Together” developed by the United Hospital Fund in New York City.

Focusing on measurement, teams tracked what worked during the collaborative, how well it worked and what the impact was on older adults and caregivers. This evaluation summary includes highlights from each team’s work.