Original Publication
Open Access

Care Transitions in the Older Adult

Published: April 18, 2008 | 10.15766/mep_2374-8265.678

Included in this publication:

  • Care Transitions Facilitator's Manual.doc
  • Care Transitions Handout.doc
  • Care Transitions Table.doc
  • Care Transitions Answer Guide Worksheet.doc
  • Final Care Transitions Vignettes.ppt
  • Settings of Care Pictures.ppt
  • PGY 23 Evaluation.doc

To view all publication components, extract (i.e., unzip) them from the downloaded .zip file.

Editor's Note: This publication predates our implementation of the Educational Summary Report in 2016 and thus displays a different format than newer publications.


Introduction: Transitions in care from the acute phase to other levels of care are an important aspect of discharge planning to facilitate adequate recovery and improve functional capacity especially in older adults. Inadequate discharge planning or discharge to an inappropriate or suboptimal care setting can lead to adverse events and avoidable rehospitalization. A good understanding of these care settings, eligibility, and financing options among medical students and residents is important in order to facilitate appropriate discharge plans and improve outcomes in older adults. Methods: This interactive case-based learning activity requires approximately 45-60 minutes, but at our institution it is delivered in the context of a 4-hour workshop. The activity consists of nine patient vignettes that allow the learners to explore a variety of discharge settings and discuss appropriate sites of care, eligibility, and financing options. Results: The evaluations indicate that this approach is well received by participants. Evaluations received from participants and assessments done using our internal 'Basic In Geriatrics 10 test' show that this session has been very useful in increasing the knowledge base of participants about sites of care for older adults and discharge planning. Discussion: Proper care of our older adults is increasingly important as the U.S. population ages. We believe this learning activity can help prepare medical students to care for this vulnerable population.

Educational Objectives

By the end of this session, learners will be able to:

  1. Identify the different care settings appropriate for different comorbidities and services offered at these facilities.
  2. Learn eligibility requirements for each site of care.
  3. Identify the financing options for each site of care.

Author Information

  • Joyce Tenover, MD, PhD: Emory University School of Medicine
  • Ugochi Ohuabunwa, MD: Emory University School of Medicine
  • Jonathan Flacker, MD: Emory University School of Medicine

None to report.

None to report.


Tenover J, Ohuabunwa U, Flacker J. Care transitions in the older adult. MedEdPORTAL. 2008;4:678. https://doi.org/10.15766/mep_2374-8265.678