Mary, 90, lived at home alone when she fell down the stairs and broke her shoulder. She had been able to manage her diabetes and heart failure on her own, later with the daily help of her son and his wife. Still, by the time that her son found her at the bottom of the stairs, she was dehydrated and disoriented. At the hospital, Mary couldn’t tell the clinicians what medications she was on or in what doses. As the hospital stay progressed, she seemed increasingly confused, and a short stay in a skilled nursing facility was recommended. In the meantime, her medications had been adjusted, and Mary was no longer certain of when to take them. No one had thought to call her internist; after all, the family thought, doesn’t the health care system work together?

For the first time, Mary didn’t feel up to managing at home alone. Her doctor’s office couldn’t schedule an appointment for more than 2 weeks, and the family had no idea where to turn. In less than a month, she was back in the hospital.

Like Mary, millions of hospital and nursing home patients are transferred or discharged each year, sometimes from the hospital to the home, often from nursing homes to hospitals and back again. More than a fifth of hospitalized Medicare beneficiaries will be rehospitalized within a month; for many, these repeated transfers mark the beginning of the end. For older people living with multiple infirmities, hospitalizations—and more generally transitioning from one setting to another—can be a perilous time. A person moving from one care setting to another faces major risks for failures in communication, in processes, and in discharge planning.

Improving care transitions and reducing unnecessary rehospitalization has become a central focus for many organizations and government programs nationwide; indeed, the Centers for Medicare & Medicaid Services have launched a half-billion-dollar program aimed at fixing problems in care transitions. The Altarum Institute Center for Elder Care and Advanced Illness is at the vanguard of improvement efforts, providing technical assistance and consulting services to programs nationwide as they work to improve care transitions—a move that would, in turn, result in fewer unnecessary hospitalizations, controlled costs, and better patient and family experiences. Altarum’s work features the launch of a new website,, which offers a blog with just-in-time information and advice on particular issues related to care transitions, from how clinicians can launch improvement efforts to how to understand the intricacies of new federal funding mechanisms.

The site also features the Care Transitions Search Widget, which optimizes Web searches for information on care transitions, providing the most relevant, accurate, and informative links to important resources in the field. The widget was developed and launched with funding from The Commonwealth Fund and technical support and guidance from Growth House, Inc. The code for the Care Transitions Search Widget can be installed, free of charge and with free technical assistance, from the Medicaring website. Many organizations around the country, including Dr. Eric Coleman’s Care Transitions Initiative and the Long-Term Quality Alliance, are now running it on their sites.

When a person is confused, is living with hearing and vision problems, has challenging financial and social issues affecting care at home, and needs to undertake complex medication and treatment regimens, that person is exceedingly likely to experience errors that actually make the situation worse. Our efforts, combined with the passion and commitment of clinicians and organizations around the country, can make that situation better.

Supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the author, Janice Lynch Schuster of Altarum Institute, and not necessarily those of The Commonwealth Fund, its directors, officers, or staff.


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